law 



sa 



mSS 



I 


















i* *'* 




'*>.,$ o'^^msx- *^<y ^£nm^\ >^^ 



v»cv 



*<fe 











* *v 













% ^v 



W 
•S^, 



'^V 



V.—.V' 

c « 



e o, 










P"""*, 









^of 



*W #Cfr \/ ••«&- V *l& **** 


























7* A <* -r.T« .0 V "o 




.0^ ^> 

4° 















♦A * v 



/% : . 



tf 










a0' 



PHYSICAL DIAGNOSIS 



^mm^^^m^m 



PHYSICAL DIAGNOSIS 



BY 



W. D. ROSE, M.D., 





LECTURER ON PHYSICAL DIAGNOSIS AND ASSOCIATE PROFESSOR OF MEDICINE 

IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY 

OF ARKANSAS 



TWO HUNDRED NINETY-FOUR ILLUSTRATIONS 



ST. LOUIS 
C. V. MOSBY COMPANY 

1917 



TV! 



Copyright, 1917, By C. V. Mosby Company 



DEC II 1917 



0O.A47S5O8 



V^ 



\ 



Press of 

C. V. Mosby Company 

1917 



PREFACE 



In the preparation of this volume the author has had in mind 
the medical student and the busy practitioner, and it has been 
his purpose to incorporate in a brief work the principles of 
physical diagnosis, together with the physical findings in. the 
commoner diseases of the respiratory and circulatory systems. 
In this connection anatomy and pathology have been considered 
from the clinical standpoint, emphasis being laid upon these 
subjects as they influence the physical manifestations of disease 
of the thorax and abdomen. 

In addition to the physical examination of the thoracic and 
abdominal viscera, it has seemed proper and practical to in- 
clude in the work the principal diagnostic signs referable to 
the head, neck, and limbs, together with a minimum examina- 
tion of the nervous system. 

The work has been profusely illustrated, in the belief that 
free illustration is the nearest approach to personal contact in 
the teaching clinic. 

The author wishes to express his appreciation to Dr. C. E. 
Shinkle, whose diagnostic table on the Barany Tests is repro- 
duced in the volume, for valuable assistance in preparing the 
section dealing with these tests. Many illustrations have been 
taken from other books, all of which have been credited in the 
text. He also wishes to thank Mrs. T. W. Marks for assistance 
rendered in the preparation of original drawings for the text ; 
and the publishers for many courtesies during the preparation 
and publication of the volume. 

W. D. Rose. 

Little Rock, Ark. 



CONTENTS 



PART I— THE THORAX 

SECTION I 
Chapter I — Clinical Anatomy of the Thorax 

Clinical Anatomy of the Thorax, 17: Surface Markings of the Thoracic 
Viscera, 27. 

SECTION II 

PHYSICAL EXAMINATIONS OF THE RESPIRATORY ORGANS 

Chapter II — Inspection 

Bi-lateral Deformities of the Thorax, 40 ; Uni-lateral Deformities of the 
Thorax, 46; Local Deformities of the Chest. 47; Respiratory Movement of 
the Thorax, 47; Abnormalities of Thoracic Expansion, 53. 

Chapter III — Palpation 

Palpation, 55; Thoracic Vibrations, 58. 

Chapter IV — Percussion 

Percussion, (55; The Normal Percussion Sounds, 70; Abnormal Percussion 
Sounds, 74; Special Sounds, 78. 

Chapter V— Auscultation 

The Respiratory Sounds in Health, B3j The Respiratory Sounds in Dis 
86; Vocal Resonance, 88; New or Adventitious Sounds. 89. 

Chapter VI— Thoracometry and Cyrtometry 
Thoracometry and Cyrtometry, !>4. 

Chapter VII — Roentgenography and Fluoroscopy 
Roentgenography and Fluoroscopy, 95. 

SECTION III 
DISEASES OF THE RESPIRATORY ORGANS 

Chapter VIII — Diseases of the Bronchi 

Acute Bronchitis, 100; Chronic Bronchitis. 102: Bronchiectasis, 103; Bion- 
chial Asthma, 105 ; Tracheo-Bronchial Stenosis, 108. 

Chapter IN — Circulatory Disturbances of the Lungs 

Pulmonary Congestion, 110; Edema of the Lungs, 111: Pulmonary In- 
farction, 112; Pulmonary Neoplasms, 114. 



8 CONTENTS 

Chapter X — Diseases of the Lungs 

Lobar Pneumonia, 116; Broncho-Pneumonia, 123; Chronic Interstitial 
Pneumonia, 129; Acute Tuberculo-Pneumonic Phthisis, 132; Chronic Ulcera- 
tive Phthisis, 133; Fibroid Phthisis, 144; Pulmonary Syphilis, 148; Pneu- 
monokoniosis, 150; Atelectasis, 154; Hypertrophic Emphysema, 156 ; Atrophic 
Emphysema, 160; Compensatory Emphysema, 161; Acute Vesicular Emphy- 
sema, 162; Interstitial Emphysema, 162; Abscess of the Lung, 163; Gangrene 
of the Lung, 166. 

Chapter XI — Diseases of the Pleura 

Acute Fibrinous Pleurisy, 169; Sero-Fibrinous Pleurisy (Pleurisy' With 
Effusion), 171; Local Pleurisy, 177; Purulent Pleurisy (Empyema), 179; 
Chronic Adhesive Pleurisy, 182; Hemothorax, 183; Chylothorax, 183; Hydro- 
thorax, 184; Pneumothorax (Pyo- or Hydro -Pneumothorax), 184. 



SECTION IV 
PHYSICAL EXAMINATION OF THE CIRCULATORY ORGANS 

Chapter XII — Clinical Anatomy 

Clinical Anatomy, 187. 

Chapter XIII — Inspection 

The Precordia, 194; Abnormal Areas of Pulsation, 194; Diastolic Collapse 
of the Jugular Veins (Friedreich's Sign), 196; Abnormal Retraction of the 
Thorax (Broadbent's Sign), 198; The Cardiac Impulse, 199; Capillary Pul- 
sation (The Capillary Pulse), 201. 

Chapter XIV — Palpation 
Palpation, 204; The Pulse, 204. 

Chapter XV — Percussion 
Variations in the Areas of Cardiac Dullness, 216. 
Chapter XVI — Auscultation 

Variations in Intensity of the Cardiac Sounds, 221; Cardiac Arrhythmia, 
225; Endocardial Murmurs, 229; Mitral Murmurs, 231; Aortic Murmurs, 234; 
Tricuspid Murmurs, 236; Pulmonary Murmurs, 237; Functional Murmurs, 
238; Multiple Murmurs and Their Diagnosis, 238; Vascular Murmurs, 240; 
Blood Pressure, 242. 

SECTION V 
DISEASES OF THE CIRCULATORY ORGANS 

Chapter XVII — Diseases of the Pericardium 
Pericarditis, 253; Hydro-Pericardium (Hydrops Pericardii), 261; Hemo- 
Pericardium, 261; Pneumo-Pericardium, 262. 

Chapter XVIII — Diseases of the Endocardium and Valves 

Acute Endocarditis, 264; Chronic Endocarditis, 267; Chronic Valvular 
Disease, 268; Aortic Insufficiency (Corrigan's Disease), 270; Aortic Stenosis, 
273; Mitral Insufficiency, 276; Mitral Stenosis, 277; Pulmonary Insufficiency, 
279 ; Pulmonary Stenosis, 280 ; Tricuspid Insufficiency, 280 ; Tricuspid Sten- 
osis, 281. 



CONTENTS V 

Chapter XIX — Diseases of the Myocardium 

A.cute Myocarditis (Acute Myocardial Degeneration), 282; Chronic Myo- 
carditis (Chronic Fibrous Myocarditis; Chronic Interstitial Myocarditis), 284; 
Cardiac Eypertrophy, 285; Cardiac Dilatation, 289; Congenital Heart Dis- 
ease, 2!i::. 

PART II— THE ABDOMEN 

SECTION I 

GENERAL EXAMINATION OF THE ABDOMEN 

Chapter XX — Clinical Anatomy op the Abdomen 

Clinical Anatomy of the Abdomen, 295. 

Chapter XXI — [nspection of the Abdomen 

Inspection of the Abdomen, 308; Variations in the Contour of the Abdo- 
men, 317. 

Chapter XXII — Palpation, Percussion, Auscultation, and Mensuration 

of Abdomen 

Palpation, 324; Percussion, 329; Auscultation, :;u'.': Mensuration, 331. 

SECTION 1L 
SPECIAL EXAMINATION OF THE ABDOMINAL VISCERA 

Chapter XXIII — The Stomach, [ntestines, and Pancreas 

Examination of the Stomach, ."..".J: The Small [ntestine, •"..".'. , : Examination 
• if the Large [ntestine, 343; Examination of the Pancreas, -"'I s . 

Chapter XXIV — Examination ok the Liver and Gall-Bladder 
Examination of the Liver ami Gall-Bladder, 353. 

Chapter XXV — Examination of the Spleen, Kidneys, Bladder, and 

Ureters 

Examination of the Spleen, 363; Examination of the Kidneys, -"'<;7: Ex- 
amination of the Bladder, .".77: Examination of the Ureters, 378. 

PART III— THE HEAD, NECK, AND EXTREMITIES 

SECTION I 
THE HEAD AXD NECK 
Chapter XXVI — Examination of the Head 
Examination of the Head, 379. 

Chapter XXVII — Examination of the Face 

Contour of the Face, 385; The Color of the Face, 389; Spasm of the 
Face, 390; The Forehead, 391; The Eyes, 391; The X^oso. 394; The Lips, 
396; The Breath, 400; The Teeth, 400; The Gums, 401; The Tongue, 401; 
The Buccal Cavity, 406; The Pharynx. 407; The Tonsils. 407. 

Chapter XXVIII — Examination of the X^eck 
Examination of the Neck, 409. 



10 CONTENTS 

SECTION II 
EXAMINATION OF THE HEAD AND ARM 

Chapter XXIX— The Hand 

The Nails, 417; The Fingers, 419; Shape of the Hand, 422; Tremor of 
the Hand, 425. 

Chapter XXX — The Forearm and Arm 
Examination of the Forearm, 428 ; Examination of the Arm, 428. 

SECTION III 
EXAMINATION OF THE LOWER EXTREMITIES 
Chapter XXXI — The Foot, Leg, and Thigh 
The Toes, 431; The Foot, 431; The Leg, 432; The Thigh, 436. 

PART IV— EXAMINATION OF THE NERVOUS SYSTEM 

SECTION I 

MOTOR AND SENSORY PHENOMENA 

Chapter XXXII — Station, Gait, and Muscular Power — Tremor 

Station, Gait, and Muscular Power — Tremor, 438. 

Chapter XXXIII — Sensory Phenomena — The Reflexes 

Sensory Phenomena — The Reflexes, 444. 

Chapter XXXIV— The Cranial Nerves 

The Olfactory Nerve, 448; The Optic Nerve, 449; The Third, Fourth, 
and Sixth Cranial Nerves, 453; Trigeminal Nerve, 456; The Facial Nerve, 
457; The Auditory Nerve, 459; The Glosso-Pharyngeal Nerve, 467; The 
Pneumo-Gastric Nerve, 467; The Spinal Accessory Nerve, 467; The Hypo- 
glossal Nerve, 468. 

APPENDIX 

Appendix, 469; Case History, 469. 



ILLUSTRATIONS 



FIG. PAGE 

1. Front view of the heart and lungs 18 

2. Pulmonary veins, seen in a dorsal view of the heart and lungs . . 19 

3. Mediastinal surface of right lung 21 

4. Mediastinal surface of left lung 21 

5. External surfaces of right and left lungs 22 

6. The bronchial tree 23 

7. The bronchiole 24 

8. The branches of a bronchiole 24 

9. The branches of a bronchiole 25 

10. The respiratory bronchiole and alveoli in cross section 26 

11. Pulmonary capillaries 26 

12. Illustrating the normal borders of the Lungs and the local ion of the 
interlobular septi. (Anterior view.) 28 

13. Illustrating normal borders of the lungs and interlobular septi. (Pos- 

terior view.) 29 

14. Illustrating the normal borders of the lungs and the location of tlie 

interlobular septi. (Lateral view.) 30 

15. Showing the position of the bifurcation of the trachea and the peri- 

tracheal and peri-bronchial glands projected upon the anterior 

surface of the chest in a young adult 30 

16. Showing the position of the bifurcation of the trachea with the peri- 

tracheal and peri-bronchial glands projected upon the posterior 

surface of the chest in a young adult 31 

17. Topographical areas of the thorax. (Anterior surface.) '■'>'■'> 

18. Topographical areas of the thorax. (Posterior surface.) 34 

19. Cross section of normal chest 39 

20. Emphysemic chest. (Front view.) 41 

21. Emphysemic chest. (Lateral view.) 4'2 

22. Transverse section of emphysematous thorax 43 

23. Lateral contour of phthisical thorax 4.". 

24. Lateral contour of emphysematous thorax 43 

25. Phthisical chest 44 

26. Phthisical thorax 45 

27. Transverse section rachitic thorax 45 

28. Transverse section of pigeon breast 45 

29. Illustrating the movements of the diaphragm and thoracic and abdomi- 

nal walls and viscera 48 

30. Showing the movements of the diaphragm and thoracic and abdominal 

walls and viscera 49 

31. Basis of Litten's phenomenon 50 

32. Cheyne-Stokes respiration 52 

33. Palpation of anterior thoracic surface 56 

34. Ulnar palpation of thorax 56 

35. Palpation of upper anterior thorax 56 

36. Palpation of pulmonary apices 56 

37. Illustrating the method of detecting lagging at the apices .... 57 

38. Illustrating the method of detecting lagging at the base 57 

39. Normal variation of vocal fremitus 58 

40. Normal variation of vocal fremitus 58 

41 A. Sagittal section through the body showing the thickness of the soft 

structures covering the apex 59 

11 



12 ILLUSTRATIONS 

FIG. PA <> E 

412>. Section through body 6 cm. to the right of the median plane, view 

from the right 60 

41C Section through body 6 cm. to the left of the median plane viewed 

from the right 61 

42. Percussion of pulmonary apices 66 

43. Percussion of lateral thoracic region 66 

44. Percussion of posterior thorax 66 

45. Illustrating a common error in percussing the apices 67 

46. Auscultatory percussion 68 

47. Showing a patient ill of tuberculosis for seven years, the right upper 

lobe and left apex being involved 72 

48. Showing patient actively ill of tuberculosis of the right apex for six 

months, with some involvement in the left 73 

49. Dullness in apical pulmonary tuberculosis 75 

50. Physical causes of change in percussion note 75 

51. Area of dullness in moderate pleural effusion 75 

52. Grocco 's sign in serofibrinous pleurisy 75 

53. Dullness in aortic aneurism 76 

54. Schematic representation of multiple areas of consolidation in bron- 

cho-pneumonia 76 

55. Changes in percussion note 77 

56. Percussion and auscultatory signs in pleurisy with effusion . . " . . 77 

57. Anatomic and pathologic basis of physical signs in percussion and 

auscultation of the thorax 78 

58. Wintrich's interrupted change of sound .......... 79 

59. Gerhardt's sign 80 

60. Mechanism of Gardner's coin test 81 

61. Stethoscope 83 

62. Auscultation of thorax 83 

63. Normal areas of bronchial and broncho-vesicular breathing. (An- 

terior view.) 84 

64. Normal areas of bronchial and broncho-vesicular breathing. (Pos- 

terior view.) 84 

65. Anatomic and pathologic basis of physical signs in percussion and 

auscultation of the thorax 86 

66. Anatomic and pathologic basis of auscultatory findings 90 

67. Usual site of pleural friction sound 92 

68. Peri-bronchial thickening in a child six and a half years of age . . 97 

69. Sacculated bronchiectasis .......; 104 

70. Curschmann's spirals. (Color Plate) 104 

71. Eosinophiles. (Color Plate) 104 

72. Char cot-Ley den crystals 106 

73. Consolidation of broncho-pneumonia 124 

74. Interstitial pneumonia with emphysema 129 

75. Illustrating caseous tuberculosis 134 

76. Illustrating pulmonary tuberculosis 135 

77. Roentgenogram 136 

78. Lung 137 

79^4. Illustrating marked regional degeneration of the muscles and other 

soft tissues over the anterior surface of the chest as a result of 

chronic tuberculosis 139 

795. Same as Fig. 79A 140 

80. Illustrating the distortion of the thoracic viscera 141 

81. Illustrating schematically the displacement of the heart to the left 145 

82. Illustrating schematically marked displacement of the heart to the 

right 146 

83 Showing schematically the compensation which has taken place between 
the two sides of the chest, and between the thoracic and ab- 
dominal cavities 147 



ILLUSTRATIONS 13 

no. page 

84. Pneumonia alba of newborn 14(» 

85. Anthracosis 151 

86. Pulmonary anthracosis 152 

87. Pulmonary capillaries 157 

88. Relations of chambers, of unopened heart to anterior chest wall . . L88 

89. Relations of opened heart to anterior chest wall L89 

ill). Interior of right auricle ami ventricle 1 1 ♦ r i 

91. Interior of right auricle and both ventricles 1!»1 

92. Fibrous rings at l»ases of cardiac valves ]s»2 

!•:;. Site of normal cardiac impulse 198 

94. Sites of palpable thrills ami pericardial friction fremitus .... 203 

95. A method of finger-tip palpation of the radial artery 205 

!Hi. Another method of finger-tip palpation of the radial artery . . . 205 

i»7. Normal sphygmogram 206 

98. Sphygmograms of pathologic pulses jus 

!)!>. Sphygmograms of pathologic typos of pulse 209 

100. Areas of cardiac and hepatic dullness and flatness 213 

101. Right and left ventricular hypertrophy 217 

102. Large pericardial effusion 217 

103. Heart in Left ventricular hypertrophy 217 

104. Right ventricular hypertrophy 217 

105. Areas of cardiac and vascular dullness 217 

L06. Auscultatory valve areas 220 

107. Sound chart 222 

108. Same as Fig. 107 222 

109. Same as Fig. 107 222 

110. Same as Pig. K>7 224 

111. Same as Fig. 107 224 

112. Physical basis of murmurs due to diminution of lumen 229 

113. Point of maximum intensity of the initial pre-systolic murmur . . 

114. Point of maximum intensity and line of transmission of initial b - 

tolic murmur 233 

11.1. Point of maximum intensity and line of transmission of aortic - - 

tolic murmur 2::.") 

116. Points of maximum intensity ami lines of transmission of aortic 

diastolic murmur 235 

117. Point of maximum intensity of tricuspid presystolic murmur . . 236 

118. Point of maximum intensity and line of transmission of tricuspid 

systolic murmur 2.".f! 

119. Point of maximum intensity and line of transmission of pulmonic 

systolic murmur 2."! 7 

120. Point of maximum intensity ami line of transmission of pulmonic- 

diastolic murmur 237 

121. Cook's modification of Riva-Rocci's blood pressure instrument . . 243 

122. Stanton's sphygmomanometer 24.°. 

123. The Erlanger sphygmomanometer with the Hirschfelder attachments 244 

124. The Janeway sphygmomanometer which has been found a convenient 

and practicable instrument 245 

125. Rogers' "Tyeos" dial sphygmomanometer 24o' 

126. The Faught blood pressure instrument 24o 

127. Detail of the dial in the "Tycos'" instrument 246 

128. Method of taking blood pressure with a patient in sitting position . 247 

129. Method of taking blood pressure with patient lying down .... 247 

130. Observation by the auscultatory method and a mercury instrument . 24S 

131. Acute fibrinous pericarditis 254 

132. Pericardial adhesions 259 

133. Malignant endocarditis of aortic valve 262 

134. Endocarditis, verrucose form 265 

135. Chronic endocarditis 268 

136. Fenestration of semilunar valves 269 



14 ILLUSTRATIONS 

FIG. PAGE 

137. Chronic verrucose endocarditis of aortic valves 271 

138. Chronic endocarditis with coalescence of two aortic cusps .... 273 

139. Enormous hypertrophy of left ventricle due to prolonged increased 

peripheral resistance 286 

140. Aortic incompetence with hypertrophy and dilatation of left ventricle 290 

141. Eeptilian heart 293 

142. Relations of abdominal and thoracic viscera 296 

143. Schematic outlines of abdominal contour 297 

144. Showing the surface and bony landmarks of the abdomen and the 

location of the abdominal aorta and its more important branches 297 

145. The abdominal surface with the rib margins and the iliac crests out-' 

lined 298 

146. Another abdominal surface, with the ribs and crests outlined . . . 299 

147. Anterior view of abdominal viscera in situ 300 

148. Surface markings of chief thoracic and abdominal viscera .... 301 

149. Relations of thoracic and abdominal viscera in the child . . . .302 

150. Surface markings of chief thoracic and abdominal viscera . . . 303 

151. The usual anatomic division of the abdomen into nine regions by 

two transverse lines and two vertical lines 304 

152. The abdominal surface divided into quadrants 305 

153. Another abdomen divided with the circle and short horizontal lines 306 

154. Establishment of collateral circulation in portal vein obstruction and 

mediastinal tumor \ . 309 

155. Abdominal arteries in a case of double iliac thrombosis of typhoid 

origin 310 

156. A small umbilical hernia, with a relaxed abdominal wall . . . . 311 

157. A large ventral hernia at the site of an operation scar 311 

158. Ventral hernia 311 

159. Stenosis in the vicinity of the splenic flexure 312 

160. Stenosis of the lower ileum from peritoneal adhesion 313 

161. Normal intestinal peristalsis 314 

162. Median grooving of the abdominal wall where there is separation of 

the recti muscles 315 

163. Obesity. (Patient lying.) 316 

164. Obesity. (Patient standing.) 316 

165. Obesity, mistaken for pregnancy by patient 317 

166. Contour of the abdomen in pregnancy with patient recumbent . . 317 

167. Tympanites, mistaken for pregnancy by the patient 318 

168. Extreme ascites 319 

169. Showing the area of dullness in moderate ascites 319 

170. Showing the reason for the disposition of the dull and resonant areas 

in a case of moderate ascites 320 

171. Indicating the relation of the dull and resonant areas in the case of a 

tumor occupying the central lower abdomen ....... 320 

172. Ascites 320 

173. Indicating the area of dullness in moderate ascites 321 

174. Indicating the area of dullness in a case of ascites 321 

175. Abdominal enlargement due to ovarian cyst 322 

176. Front view of general enteroptosis 322 

177. Palpation of the abdomen. First step 325 

178. Palpation with one hand 325 

179. Palpation with both hands 325 

180. Deep palpation with both hands 325 

181. Testing the thickness of the abdominal wall . . 326 

182. Testing the thickness of the abdominal wall 326 

183. Various areas of significant point-tenderness 327 

184. Trying for a fluid wave across the abdomen 328 

185. Differentiating a fat-wave from a fluid-wave 328 

186. Ordinary percussion 330 

187. Deep percussion 330 



ILLUSTRATIONS 15 

FIG. PAGE 

L88. Showing the lines for mensuration 330 

is<). The central upper abdomen 333 

]!)(). Anatomic subdivisions of stomach 334 

L91. Form and surface topography of empty stomach 334 

192. Musculature of the stomach 334 

1!).'!. Traube's semilunar space 335 

194. Palpation of the epigastrium 335 

195. Epigastric pressure point 336 

196. Dorsal pressure point in gastric ulcer 337 

197. Showing the region for tenderness or a mass from disease of the 

stomach or pancreas 337 

198. The left upper abdomen 340 

199. The duodenum 341 

200. Relations of large intestine to kidneys 342 

201. The right lower abdomen 343 

202. Indicating the point to seek for appendix tenderness 344 

203. Palpating for tenderness or a mass in the appendix region . . . 344 

204. Palpating for the appendix 344 

205. Another method of palpating the appendix .",44 

206. The left lower abdomen 345 

207. Palpating for tenderness or a mass in the umbilical region . . . 346 

208. Palpation of ascending colon 347 

209. Palpation of the descending colon 347 

210. Relations of pancreas to adjacent viscera .".4 ( .i 

211. Topographical relations of liver, bile passages, and pancreas . . 350 

212. Position and relations of pancreas 350 

213. Pancreas and duodenum 351 

214. The right upper abdomen 352 

215. Superior surface of liver .:.", | 

216. Inferior surface of liver 354 

217. Corset liver 355 

218. Indicating the site for tenderness or a mass due to disease of the 

gall bladder 356 

219. Palpation of liver 356 

220. Hepatic enlargement due to carcinoma of head of pancreas . . . 357 

221. Dorsal pressure point in chololithiasis 358 

222. Palpating for general tenderness of the liver 359 

223. Showing the site for tenderness of the left lobe of the liver . . . 359 

224. Indicating the region for dullness from enlarged liver 360 

225. Indicating the area to search for splenic tenderness or enlargement 364 

226. Indicating the region for dullness from enlarged spleen .... 365 

227. Palpation of the spleen 365 

228. Splenic enlargement in leukemia 366 

229. Surface markings of kidneys, uterus, and abdominal vessels . . . 368 

230. Surface markings of pleura, lungs, interlobar fissures and relations 

of pleural cavities to kidneys 369 

231. Palpation of the kidney ..." 370 

232. Indicating the region for kidney tenderness in front, on the right side 371 

233. The point for kidney tenderness laterally 371 

234. The point for kidney tenderness posteriorly 372 

235. The area for left kidney tenderness in front 372 

236. Method of palpating for a mass in the kidney region 373 

237. Point for kidney tenderness laterally 374 

238. Points for kidney tenderness in the back 374 

239. Relation of the kidney to the lower margin of the last rib . . . 375 

240. Showing technic of physical examination for nephroptosis .... 376 

241. Showing technic of physical examination for nephroptosis . . . 376 

242. Indicating the site to search for tenderness of the right ureter . . 37S 

243. Palpating for tenderness or thickening about the right ureter . . 378 

244. Alopecia areata 381 



16 ILLUSTRATIONS 

TIG. PAGE 

245. Alopecia areata 382 

24(5. Syphilitic alopecia . . ■ 383 

247. Face of acromegaly 386 

24S. A case of congenital myxedema 386 

249. Face of myxedema . .' 387 

250. Leprosy 387 

251. Facial" hemi-atrophy . 388 

252. Saddle-nose . . 395 

253. Mucous patches 396 

254. Chancre of the lip of one month's duration 396 

255. Prickled-celled carcinoma of the lower lip . .' 397 

256. Double harelip and cleft palate 398 

257. Case of complete double cleft 398 

258. Complete double cleft to the lip 399 

259. Noma 399 

260. Hutchinson's teeth 400 

261. Illustrating tuberculous lesions of the tongue 403 

262. "Cobblestone tongue" 404 

263. Large cystic goiter 410 

264. Goiter 410 

265. Palpation of submaxillary and submental glands 411 

266. Congenital hemangioma of neck 412 

267. Hodgkin's disease \ . 413 

268. Cervical glands commonly involved in tuberculosis 414 

269. Bronchial cyst 415 

270. Bronchial cyst 415 

271. Hypertrophy of the nails 418 

272. Symmetrical atrophy of nails , 418 

273. Heberden's nodes 420 

274. Pulmonary osteo-arthropathy 420 

275. Arthritis deformans 421 

276. Morvan's disease 421 

277. Spade hand 423 

278. Claw hand . 423 

279. Accoucheur's hand . 424 

280. Wrist-drop . . 424 

281. Pellagra 426 

282. Pellagra in child less than 3 years old .427 

283. Lipoma of arm 429 

284. Gangrene of toes 431 

285. A case of rickets 433 

286. A case of rickets .433 

287. A case of rickets 434 

288. Showing extreme case of bow-legs ............ 434 

289. Varicose ulcer of leg 435 

290. Osteosarcoma of femur 436 

291. Little's disease . 441 

292. Little's disease 441 

293. Facial paralysis 458 

294. Facial paralysis 458 



PHYSICAL DIAGNOSIS 



PART I. THE* THORAX 



SECTION I 



CHAPTER I 

CLINICAL ANATOMY OF THE THORAX 

The thorax, or chest, composed of the bony structures, the verte- 
bral column and ribs, clothed with the associated soft structures, 
comprises two large chambers, one on cither side of the median 
line, the pleural cavities, intervening between which is the medi- 
astinum. 

The pleural cavil i<s, occupying the lateral regions of the thoracic 
cavity, extend upward into the base of the neck to the extent of 
one to one and one-half inches above the clavicle, and downward as 
low as the attachment of the diaphragm to the lateral thoracic 
walls. The pleural cavity is lined by a thin serous membrane, the 
pleura, which clothes its walls, in which situation it is termed the 
parietal pleura. The same membrane is reflected on to the lung at 
its root, clothing the external surface of the lung completely and 
dipping into the fissures, the visceral pleura. During health the 
pleural membrane is moistened with a small amount of serous 
fluid, which causes the visceral and parietal pleurae to glide noise- 
lessly over each other during the movements of respiration. In 
inflammation of the membrane, however, the pleural surface be- 
comes roughened and coated with a variable amount of fibrinous 
exudate, giving rise to a grating sound during the respiratory 
movements, the friction rub. 

The mediastinum, the portion of the thoracic cavity intervening 
between the pleural cavities, bounded anteriorly and posteriorly 
by the chest walls, and laterally by the reflections of the parietal 
pleura from the anterior to the posterior wall of the chest, is 
divided into four parts, the superior, posterior, anterior, and middle 
mediastina. 

17 



18 PHYSICAL DIAGNOSIS 

The superior mediastinum is the portion of the mediastinal 
cavity situated above the lower border of the manubrium sterni an- 
teriorly and the lower border of the fourth dorsal vertebra pos- 
teriorly. The principal structures occupying the superior medias- 
tinum are the trachea, esophagus, thoracic duct, the arch of the 
aorta, and the great veins entering the base of the heart. 

The posterior mediastinum is formed by the downward continua- 




Fig. 1. — Front view of the heart and lungs. (From Gray.) 

tion of the posterior portion of the superior mediastinum, extend- 
ing downward to the upper diaphragmatic surface, having anterior 
to it the pericardium and heart. It contains the thoracic aorta, 
esophagus, thoracic duct, pneumogastric nerves, and the azygos 
veins, as well as the mediastinal lymphatic glands, which are some- 
times the seat of enlargement or malignant disease. 

The middle mediastinum, situated below the anterior portion of 
the superior mediastinum, and between the anterior and posterior 
mediastina, is the most important portion of the mediastinal cavity 
from the standpoint of the student of physical diagnosis, as it con- 
tains the pericardium and heart, the ascending aorta, the bifurca- 



CLINICAL ANATOMY OF THE THORAX 



19 



tion of the trachea, the bronchi and bronchial glands, the pulmo- 
nary artery with its two primary branches, the lower portion of 
the superior vena, and its junction with the azygos veins. 

The anterior mediastinum is a narrow space situated behind the 
sternum with the pericardium and reflections of the parietal 
pleura posteriorly and laterally. It is of little diagnostic interest, 
save that it contains a few lymphatic glands which may become the 
seat of malignant disease. 

The thoracic viscera comprise the trachea and bronchi, the lungs, 
the pericardium, and the heart, with the great vessels arising from it. 

The trachea extends almost vertically downward from the lower 
border of the larynx, at the level of the sixth cervical vertebra, to 




■ : ■ t Of 
»Z»dOS 
:« or hjl- 
a» Jiarcnv 



Fig. 2. — Pulmonary veins, seen in a dorsal view of the heart and lungs. The lungs 
have been pulled away from the median line, and a part of the right lung has been 
cut away to display the air ducts and blood vessels. (Gray, after Testut.) 



the lower border of the fourth dorsal vertebra, where it divides to 
form the two primary bronchi. 

The bronchi, right and left, pass obliquely downward and out- 
ward to enter the roots of their respective lungs, the left bronchus 
being slightly smaller than the right, and pursuing a more oblique 
course than does the right, which passes more directly downward. 
As the left bronchus is smaller and more deeply placed in the 
thoracic cavity than is the right, and as it forms a more acute angle 
with the trachea than does the corresponding bronchus of the op- 
posite side, physical signs arising within it are not conducted to 



20 PHYSICAL DIAGNOSIS 

the surface of the chest with the same degree of intensity as are 
similar sounds arising within the right bronchus. 

The lungs, suspended by their respective roots, and covered 
upon their surfaces by the visceral pleura, hang free within the 
pleural cavities. The left lung has two lobes, separated by a fissure 
which extends well in toward the root of the lung and which is 
lined by a reflection of the visceral pleura. In inflammation of the 
pleura the portion of the membrane dipping into the fissure may 
be the only portion of the membrane involved, leading to a condi- 
tion of interlobar pleurisy. The upper lobe of the left lung com- 
prises a large portion of the external surface and the entire an- 
terior border of the lung, while the lower lobe comprises the en- 
tire base and the greater portion of the posterior border of the 
lung. This is an anatomical fact of considerable clinical impor- 
tance, as during physical examinations it is often desirable to ascer- 
tain whether a morbid process having its inception in the apex or 
upper lobe of the lung has progressed to the lower lobe. 

The right lung has three lobes which are separated by two fis- 
sures. The upper lobe comprises the apex, a little more than 
half of the external surface and the portion of the anterior border 
of the lung above the level of the fourth costal cartilage. The 
lower lobe comprises the entire base of the lung, but only a small 
portion of its external surface. The middle lobe is a wedge-shaped 
portion intervening between the upper and lower lobes, comprising 
the anterior portion of the external surface of the lung below the 
fourth costal cartilage. 

The external surface of each lung is convex, w T hile the internal 
surface, which is in contact with the mediastinum, presents depres- 
sions corresponding to the mediastinal structures with which it is 
in relation. The internal surface of each lung is marked by a 
rather deep depression, which receives the pericardium with the 
heart, this depression being considerably deeper upon the left 
lung, owing to the projection of the heart toward the left side of 
the thoracic cavity. Just above and behind this depression each 
lung presents the hilus or pulmonary root for the entrance of the 
primary bronchus, blood vessels, lymphatics, and nerves of the 
lung, while extending downward from the hilus is a fold of the 
reflected pleura, the ligamentum latum pulmonis. 

The internal surface of the left lung is traversed by a fairly deep 
groove for the lodgment of the aorta, which curves above the left 
bronchus and descends behind this tube. A second groove passes 



CLINICAL ANATOMY OF THE THORAX 



21 



ANTERIOR 
BORDER 




LINE OF REFLECTION 
OF PULMONARY 
PLEURA ONTO 
ROOT OF LUNG 



LIGAMENTUM 
LATUM PULMONIS 



iMg. 3. — Mediastinal surface of right lung. (From Gray.) 



SUBCLAVIAN 
GROOVE 



PULMONARY 
ARTERY 



BRONCHIAL 
ARTERIES 



BRONCHIAL 
LYMPH NODE 



LIGAMENTUM 

LATUM 

PULMONIS 




BRONCHUS 



PULMONARY 
VEINS 



CARDIAC 
DEPRESSION 



INFERIOR 
BORDER 



Fig- 4. — Mediastinal surface of left lung. (From Gray.) 



22 



PHYSICAL DIAGNOSIS 



upward from the aortic groove, where that vessel arches over the 
left bronchus, which lodges the subclavian artery. 

The internal surface of the right lung is traversed by a groove, 
which, arching over the right bronchus, lodges the vena azygos 
major, while extending upward from this groove is a second de- 
pression, which lodges the superior vena cava. 

The internal structure of the lung is very intimately related to 
many symptoms and signs arising during disease of the pulmo- 
nary organs. The bronchi, which enter the lungs at the hilus, 
branch dichotomously, until very fine branches, termed bron- 
chioles, are formed. 




Fig. 5. — External surfaces of right and left lungs. (From Gray.) 



In the bronchiole there is a gradual transition of the stratified 
columnar ciliated epithelium of the bronchi into simple columnar 
epithelium, which in turn, near the distal extremity of the ter- 
minal bronchiole gives place to small groups or islands of the 
flat, non-nucleated epithelial cells, respiratory epithelium. The 
epithelial lining of the terminal bronchiole rests upon a thin base- 
ment membrane, beneath which is a tunic containing numerous 
elastic fibers and circularly disposed smooth muscle fibers, spasm 
of which may play a part in the production of the paroxysm of 
bronchial asthma. 

Each terminal bronchiole leads to an irregularly pyramidal 
chamber, the infundibulum, which constitutes "the blood-vascular 
unit" of the lung. The walls of the infundibula comprise a series 



CLINICAL ANATOMY OF THE THORAX 



23 



of blind pouches, the alveoli, which are lined with a single layer 
of flat respiratory epithelium resting upon a delicate basement 
membrane, containing many elastic fibers, which afford to the 
lung an elasticity or resilience, which plays an important part in the 
phenomenon of expiration. 

The infundibula are invested by a dense capillary net-work 




Fig. 6. — The bronchial tree. The walls of the bronchi contain cartilage in incomplete 
rings or plates distributed about their entire circumference. The cartilage and the elastic 
tissue make the tubes firm-walled; only the fine branches of one mm. or less in diameter 
have no cartilage, and are consequently collapsible. (From Brown.) 



derived from branches of the pulmonary artery, which accom- 
pany the bronchi and bronchioles, the capillary plexus surround- 
ing each infundibulum being disposed in a single layer, with no 
communication with the net-work of neighboring infundibula. 
The blood in these capillaries is very intimately exposed to the air 



24 



PHYSICAL DIAGNOSIS 







Fig. 7. — The bronchiole. (Highly magnified.) The bronchioles are irregular tubules 
of a diameter of one mm. or less. The walls consist of a thm flattened epithelium plus 
a thin layer of non-striated muscle. (Brown, after Bohm, Davidoff, and Huber.) 




Fig. 8. — The branches of a bronchiole. Each bronchiole has numerous divisions; all 
are irregular. The final endings, the alveoli, are irregular air cells with thin walls. The 
cross section of the alveoli arising from one bronchiole is far greater than that of the 
bronchiole. A, respiratory bronchiole; B, alveolar ducts; C, atria; D, air sacs. The 
finer markings show the alveoli. (From Brown.) 



CLINICAL ANATOMY OF THE THORAX 



25 



in the infundibula, as they are separated only by three very thin 
membranes; namely, the endothelium of the capillary wall, the 
delicate basement membrane of the infundibula, and the single 
layer of flat epithelium lining the infundibula. 

In hypertrophic emphysema, when the inter-alveolar septa are 
destroyed, as the capillary plexus of each infundibulum is dis- 
tinct and has no connection with that of neighboring infundibula, 







/%Jft 


^ 


;^SS=f ^=SJ 


A€S ALVEOLI 


ALVEOLI \ 
DUCT 




y^ BRONCHIOLE 


\x ^%= 






_^^rvAfr r^Yyffift 




\ W -^ 


£~>&^\&<ftr 






JifNuir 








*|lvEyZ/^ 


RESPIRATORY 
BRONCHIOLE 



Fig. 9. — The branches of a bronchiole, showing irregularities and bnlgings which air 
from a remote air cell traverses to get to the main bronchiole of a lobule. (Brown, after 
Gray.) 

the amount of blood exposed to the air in the large cavities which 
are formed by coalescence of several infundibula is greatly re- 
duced, leading to dyspnea on slight exertion in this class of 
patients. 

The lymphatics- of the lungs drain into the deep pulmonary 
lymph nodes and the bronchial and mediastinal glands, with the 
result that these glands are early involved in tuberculous infec- 



26 



PHYSICAL DIAGNOSIS 



Respiratory — 
bronchiole' 







Fig. 10. — The respiratory bronchiole and alveoli in cross section. The broad expanse 
of alveoli comprises a maze of blind pockets in which air may wander around before 
reaching the respiratory bronchiole. Even after reaching the respiratory bronchiole, the 
bulgings and indentations of the walls offer additional pockets for air to enter and leave 
before reaching the bronchiole. (Brown, after Bohm, Davidoff, and Huber.) 




Fig. 11. — Pulmonary capillaries. The walls of the alveoli are thickly studded with 
capillaries; any marked alteration of alveolar air tension will therefore have a profound 
effect upon the circulation. (Brown, after Bohm, Davidoff, and Huber.) 



CLINICAL ANATOM Y OF THE THORAX 27 

tion of the lungs, or when the lung becomes the seat of malignant 
disease. Similarly these glands serve as niters for the irritant 
dusts which reach the finer bronchioles and infundibula in pneu- 
monokoniosis. 

The clinical anatomy of the heart and pericardium is discussed 
in a subsequent section. 

SURFACE MARKINGS OF THE THORACIC VISCERA 

The Pleura. — The surface markings of the pleura upon either 
side correspond to lines drawn upon the chest wall from either 
sterno-clavicular articulation to the transverse ridge which marks 
the junction of the manubrium and gladiolus of the sternum. 
Thence the anterior borders of the pleural membranes pass down- 
ward parallel with each other, slightly to the right of the mid- 
sternal line to the fifth intercostal space. At this point the 
two membranes separate. 

The right pleura continues directly downward almost to the 
ensiform cartilage, whence it pursues an outward and downward 
course toward the spinal column, crossing the seventh rib in the 
mid-clavicular line, the ninth rib in the mid-axillary line, and the 
eleventh rib in the scapular line. 

At the level of the fifth interspace the left pleura passes out- 
ward and downward to the posterior surface of the sixth costal 
cartilage; crosses this cartilage vertically; and passes downward 
and backward to the spinal column, occupying a slightly lower level 
than does the lower border of the right pleura. 

The upper level of the supra-clavicular portion of the pleura 
is indicated by a line drawn obliquely upward and outward from 
the sterno-clavicular articulation on either side crossing the lower 
portion of the root of the neck in such a direction as to curve up- 
ward and reach the seventh cervical vertebra. The highest point 
of the curve, which corresponds to the apex of the pleural cavity, 
is one to one and one-half inches above the clavicle. 

Upon the posterior surface of the chest the course of the pleura 
is represented by drawing a line along either side of the vertebral 
column, passing vertically downward from the seventh cervical 
vertebra to the articulation of the eleventh rib with the spinal 
column, whence the line is continued downward and outward in a 
gentle curve to meet the line of reflection of the anterior portions 
of the membrane. 



28 



PHYSICAL DIAGNOSIS 



The Lungs. — The borders of the lungs follow closely the line of 
reflection of the pleura, save that inferiorly the lower borders of 
the lungs fall short of the pleura by one interspace, being found 
at the sixth rib in the mid-clavicular line, the eighth rib in the 
mid-axillary line, and the tenth rib in the scapular line. The 
interval between the lower border of the lung and the pleura, 
representing one intercostal space on the surface of the chest, is 
the complementary sinus, into which the lower border of the lung 




LOWER MARGIN 
Of LUNG-- 



LOWER MARGIN \ 
OF PUURA---~\ 



OWtR MARGIN 
Of LUNG 



-lower margin 
op pleura 



Fig. 12. — Illustrating the normal borders of the lungs and the location of the interlobular 
septi. Anterior view. (Pottenger, after Corning.) 



descends during full inspiration. The surface markings should be 
borne in mind when determining the total expansion of the lungs 
by percussion. 

Fissures of the Lungs. — The position of the great fissure which 
intervenes between the upper and lower lobes in both lungs is rep- 
resented by a line drawn upon the chest wall from the spinous 
process of the third dorsal vertebra, obliquely downward and for- 
ward to the sixth rib in the mid-clavicular line. The fissure in- 



CLINICAL ANATOMY OF THE THORAX 



29 



tervening between the upper and middle lobes of the right lung 
is represented by a line drawn upon the surface of the thorax from 
the. apex of the axilla almost horizontally forward to the sternum at 
the articulation of the fourth left costal cartilage. 

Trachea and Bronchi. — The course of the trachea corresponds to 
a line drawn from the upper margin of the manubrium sterni to 




LOWER ttARGLM 
OF LUHG 



LOWER. ttARG IN 
OF PLEURA-- 



Fig. 13. — Illustrating normal borders of the lungs and interlobular septi. Posterior view, 
(Pottenger, after Corning.) 



the level of the upper margin of the second rib in the median line. 
At this point the trachea divides into the two primary bronchi, 
which diverge from each other, passing downward and outward, 
the right bronchus inclining more directly downward than does 
the left. 

Landmarks of the Normal Chest. — There are a number of nor- 
mal anatomical landmarks which are visible or palpable upon the 
surface of the chest, which may be utilized in the description and 



PHYSICAL DIAGNOSIS 




Fig. 14. — Illustrating the normal borders of the lungs and the location of the in 
septi. Lateral view. A, right; B, left. (Pottenger, after Corning. 



nd the location of the interlobula 




Fig. 15. — Showing the position of the bifurcation of the trachea and the peri-tracheal 
and peri-bronchial glands projected upon the anterior surface of the chest in a young 
adult. (Pottenger, after Gerhartz.) 



CLINICAL ANATOMY OF THE THORAX 



31 



Localization of morbid conditions arising within the thoracic cav- 
ity. 

i\t the upper border of the manubrium sterni a slight depres- 
sion is visible, the supra- sternal notch, which is frequently the 
site of abnormal pulsations. During expiration the upper border 
of the sternum, which limits the supra-sternal notch inferiorly, oc- 
cupies a position corresponding to the disk between the second 
and third dorsal vertebra 1 . The distance between the vertebral 
column and the notch is approximately two inches, representing 
the inlet of the thorax. 

At the lower extremity of the sternum there is a second depres- 
sion, the scrobiculus cordis or pit of the stomach, which corre- 
sponds to the midpoint of the body of the ninth dorsal vertebra. 




Fig. 16. — Showing the position of the bifurcation of the trachea with the peri-tracheal 
and peri-bronchial glands projected upon the posterior surface of the chest in a young 
adult. (Pottenger, after Piersol.) 



The sternum occupies the median line of the anterior surface of 
the thorax, surmounted by the supra-sternal notch, with the scro- 
biculus cordis at its lower extremity. The average length of the 
sternum is six inches. 

The angulus ludovici, or angle of Louis, is a transverse ridge 
upon the sternum, marking the junction of the manubrium and 
gladiolus. It is usually visible and is always palpable. This 
ridge corresponds to the level of the junction of the second costal 
cartilage with the sternum and is of service as a starting point in 
counting the ribs. 

The clavicle, at all times a conspicuous landmark upon the 



32 PHYSICAL DIAGNOSIS 

anterior thoracic surface, in apical lesions of the lungs becomes 
very conspicuous, contrasting markedly with the depressions above 
and below the bone. 

Upon either side of the thorax there are twelve ribs and eleven 
intercostal spaces. The first rib lies rather deeply beneath the 
clavicle, but the remaining ribs are readily palpated. Each inter- 
costal space is named in accordance with the number of the rib 
above it. Thus, the first intercostal space occupies the interval be- 
tween the first and second ribs. 

In counting the ribs one of several methods may be employed. 
In counting the ribs upon the anterior surface of the chest it is con- 
venient to begin at Louis' Angle which, as stated, corresponds to 
the second chondro-sternal junction. In counting the ribs upon 
the posterior surface of the thorax the lower angle of the scapula 
may be used as a starting point, as the tip of this bone overhangs 
the seventh rib when the chest is in repose. Some clinicians prefer 
to count the ribs upward by locating the tip of the twelfth rib, 
which can be palpated in many subjects. In counting the ribs 
upon the lateral aspect of the thorax the highest digitation of the 
serratus magnus muscle overlies the sixth rib. The muscle may 
be rendered tense by directing the patient to raise the arm out- 
ward to a horizontal position. 

The mammary gland in the male is rudimentary. In the female 
subject, however, it is well developed, extending from the third 
to the seventh interspace in the mid-clavicular line. In the male 
subject the nipple usually is a reliable guide to the fourth inter- 
space, but in the female it is an entirely unreliable landmark, ow- 
ing to the pendulous condition of the breast. 

The scapula overlies the dorsal aspect of the bony thorax, extend- 
ing along the vertebral column from the second to the seventh rib. 
Always visible, it becomes excessively so and stands out prom- 
inently in the phthisical thorax of pulmonary tuberculosis. 

The spine in muscular individuals is represented by a median 
groove, and the spinous processes are hardly palpable. But in thin 
subjects and in children many of the processes are visible; and 
when the subject bends the trunk forward they are readily pal- 
pated and counted. The spine of the seventh, cervical vertebra 
(vertebra prominens) is always prominent, and may be employed 
as a starting point in counting the spinous processes. Or the in- 
ferior angle of the scapula, which corresponds to the level of the 
seventh dorsal spinous process may be employed as a starting point 



CLINICAL ANATOMY OF THE THORAX 



33 



in the enumeration. Lateral or antero-posterior curvature of the 
spinal column is frequently noted, with or without pathologic sig- 
nificance. 

Topographical Regions of the Thorax. — For purposes of clini- 
cal description and for convenience in localizing pathologic lesions 
arising within the thorax, a number of arbitrary regions may be 
outlined upon the surface of the chest by means of arbitrary verti- 
cal and horizontal lines. 

Vertical Lines. — The mid-sternal line is drawn vertically 
through the center of the sternum from the midpoint of the upper 




Fig. 17. — Topographical areas of the thorax. Anterior surface. (From Butler.) 

border of the manubrium sterni to the tip of the ensiform cartilage. 

The sternal line is drawn along the lateral border of the sternum 
from the sterno-clavicular articulation to the tip of the ensiform 
cartilage, and is continued downward and outward along the lower 
border of the costal arch. 

The mid -clavicular line is a vertical line dropped from the mid- 
point of the clavicle. It often passes through the nipple and is 
hence termed the nipple line, or mammary line. 



34 



PHYSICAL DIAGNOSIS 



The para-sternal line is a vertical line midway between the 
sternal line and the mid-clavicular line. 

The anterior axillary line is a vertical line dropped from the 
anterior axillary fold. 

The mid-axillary line is a vertical line dropped from the apex 
of the axilla along the lateral thoracic wall. 

The posterior axillary line is a vertical line let fall perpendicu- 
larly from the posterior fold of the axilla. 




Fig. 18. — Topographical areas of the thorax. Posterior surface. (From Butler.) 



The scapular line is a vertical line drawn upon the posterior 
surface of the thorax, passing through the inferior angle of the 
scapula. 

The mid-spinal line is a vertical line drawn along the spinous 
processes of the dorsal vertebrae. 

Horizontal Lines. — The crico-clavicular line is drawn from the 



CLINICAL ANATOMY OF THE THORAX 35 

cricoid cartilage outward with slight inclination downward to the 
outer extremity of the clavicle. 

The clavicular line is drawn outward with a slight inclination 
upward, following the course of the clavicle. 

The third costal line, extends horizontally outward from the 
sternal line at the level of the articulation of the third costal car- 
tilage with the sternum, to the anterior axillary line. 

The sixth costal line extends outward from the sternal line at 
the sixth chondro-sternal articulation to the posterior axillary 
line. 

The scapular spinal line is drawn along the course of the spine 
of the scapula. 

The infra-scapular line is drawn horizontally between the in- 
ferior angles of the scapula. 

The twelfth dorsal line is drawn from the spinous process of 
the twelfth dorsal vertebra outward and downward to the posterior 
axillary line. 

Regions. — By means of these arbitrary lines a number of regions 
are marked off upon the chest Avail. 

The sternal region overlies the sternum, and is bounded above 
by the supra-sternal notch, below by the scrobiculus cordis, and 
laterally by the sternal lines. 

The supra-clavicular region lies above the clavicle, bounded above 
by the crico-clavicular line, and below by the clavicular line. 

The infra-clavicular region, lies immediately below the clavicle, 
and is bounded above by the clavicular line, below by the third 
costal line, internally by the sternal line, and externally by the 
anterior axillary line. 

The mammary region, lies immediately below the infra-clavicu- 
lar region, limited above by the third costal line, below by the 
sixth costal line, internally by the sternal line, and externally by 
the anterior axillary line. 

The hypochondriac region, lies below the mammary region, be- 
tween the sixth costal line, the anterior axillary line, and the 
downward and outw r ard continuation of the sternal line along the 
line of the costal arch. 

The axillary region occupies the lateral aspect of the chest, 
bounded above by the apex of the axilla, below by the sixth costal 
line, anteriorly by the anterior axillary line, and posteriorly by the 
posterior axillary line. 

The infra-axillary region, lying below the axillary region, is 



36 PHYSICAL DIAGNOSIS 

bounded by the anterior and posterior axillary lines, the sixth 
costal line and the downward continuation of the sternal line. 

The supra-scapular region overlies the supra-scapular fossa, 
limited below by the scapular spinal line. 

The scapular region, overlying the infra-scapular fossa, is 
limited above by the scapular spinal line, below by the infra-scapu- 
lar line, externally by the posterior axillary line. 

The infra-scapular region is limited above by the infra-scapular 
line, below by the twelfth dorsal line, externally by the posterior 
axillary line, and internally by the mid-spinal line. 

The interscapular region occupies the interval between the scapu- 
lar line and the mid-spinal line, being" limited below by the infra- 
scapular line. 



SECTION II 

PHYSICAL EXAMINATION OF THE RESPIRATORY 

OKGANS 



CHAPTER II 
INSPECTION 

Objects and Technic. — In the study and analysis of disease of 
the respiratory organs inspection is employed to determine the 
state of the exterior of the thorax, various unilateral and bilateral 
variations from the normal contour and size of the thorax, the 
presence of local prominences and depressions, the character and 
frequency of the respiratory movements of the thorax, the degree 
of expansion of the two sides of the thorax, and the presence of 
abnormal pulsations visible upon the surface of the thorax. 

During inspection of the thorax the patient's clothing should be 
removed to the waist, as a full and direct exposure of the chest 
is essential to a proper examination by all the methods employed 
in physical diagnosis. During the examination the erect or re- 
cumbent posture may be assumed by the patient, preferably the 
former. The light should fall directly upon the area under investi- 
gation, the source of the light passing over the examiner's shoul- 
ders. In the course of the examination the examiner should view 
the chest from the front, from the sides, and from behind. He 
should then stand above the patient and look downward over the 
shoulders; and, finally, with the patient in the recumbent posture 
the thorax should be inspected from below, the examiner standing 
near the feet of the patient. 

During inspection of the thorax, as in all physical examinations, 
the attitude of the patient should be natural and unconstrained. 
During inspection of the front of the thorax the patient should 
sit erect with the arms hanging naturally at the sides. During in- 
spection of the lateral regions of the thorax the patient's hands 
should be clasped behind the head, allowing a free exposure of the 
axillary regions. 

37 



38 PHYSICAL DIAGNOSIS 

After inspecting the thorax by direct light, the same procedure 
should be observed with the patient exposed to oblique illumina- 
tion. This latter method of examination will often reveal a patch 
of deficient expansion so slight as to quite escape detection during 
the examination in direct light. 

The Surface of the Chest. — Inspection of the surface of the 
thorax may reveal abnormalities in the condition of the skin, the 
subcutaneous tissues and musculature, changes in the superficial 
vessels of the thorax, or changes in the mammary gland or the 
ribs. 

The skin of the thorax in health is smooth and glossy and is. 
lubricated with the proper amount of sebaceous material. The 
skin of the male chest is frequently clothed with a greater or less 
abundance of hair, which may obscure the true state of the skin. 
Certain diseases not referable to the respiratory organs produce 
pigmentation of the skin, notably hepatic disorders, Addison's 
disease, chronic malarial poisoning, and the cachexia of malig- 
nant disease; whereas other conditions, as anemia and chronic 
pulmonary tuberculosis, are attended with an abnormally pale 
and dry skin. Moreover, various skin diseases produce eruptions 
upon the skin of the thorax, and the skin of this region may be the 
seat of scars from trauma or syphilis. 

The superficial veins of the thoracic wall, scarcely visible dur- 
ing health, are engorged and tortuous when intra-thoracic lesions 
interfere with the return of the blood to the right heart. Thus 
engorgement or undue prominence of the superficial veins of the 
thorax may be significant of pressure exerted within the medias- 
tinum by a tumor, aneurism, or enlarged heart. Engorgement of 
the veins over the lower region of the thorax, communicating with 
similarly distended veins over the abdomen, associated with the 
caput medusa?, is indicative of portal vein obstruction. 

Edema of the chest wall occurs as a part of general anasarca. 
Localized edema of the chest wall points to suppurative disease 
within the thorax, as in empyema necessitatis. 

Condition of the Subcutaneous Tissues and Muscles. — Wasting 
of the subcutaneous tissues and intercostal muscles accompanies the 
emaciation of chronic tuberculosis, diabetes, and paralysis of the 
intercostal muscles, rendering the ribs unduly prominent. 

The Ribs. — Not particularly perceptible upon inspection save in 
the lower axillary region, the ribs in chronic wasting diseases be- 
come very conspicuous landmarks upon the thorax. In rickets 



INSPECTION OF RESPIRATORY ORGANS 



39 



there is permanent deformity of the terminal ends of the ribs, 
constituting the Rachitic Rosary of this disease. 

Mammary Gland. — In males a peculiar hypertrophy of the 
usually rudimentary mammary gland has been noted in some cases 
of pulmonary tuberculosis. 

The Size and Contour of the Thorax. — The size and shape of the 
thorax are remarkably perverted from the normal by several dis- 
eases of the respiratory system, as well as in certain diseases of 
other origin, and occasionally as the result of occupation. In cer- 
tain of these diseases the chest becomes permanently fixed in de- 
formity, and the diagnosis may at times be made by a glance at the 
configuration of the chest. 

The Normal Thorax. — The norma] thorax is only recognized 
after long clinical experience. In the normal thorax the shoulders 
are usually on a level, the clavicles are not unduly prominent, al- 




Fig. 19. — Cross section of normal chest. (Redrawn from Gee.) 



though slight depressions in the supra- and infra-clavicular fossae 
are not incompatible with good physical health. The two sides 
of the normal chest are seldom exactly symmetrical. As a rule 
the right side is better developed than is the left. The sternum 
in the normal thorax presents a slight forward inclination from 
its top to its lower extremity, and usually a visible transverse ridge 
at the angle of Louis. The bony thorax is clothed with a healthy 
musculature so that the interspaces are neither shrunken nor pro- 
truding. The skin is smooth and moistened by a moderate amount 
of sebaceous material. 

A cross section of the normal chest is elliptical, the transverse 
diameter exceeding the antero-posterior diameter by one-fourth. 
In the thorax of the child this relation between the transverse and 
antero-posterior diameters does not obtain, as the child's thorax is 
almost circular upon cross-section. 



40 PHYSICAL DIAGNOSIS 

BI-LATERAL DEFORMITIES OF THE THORAX 

The Emphysematous Thorax (Barrel Chest). — The emphysema- 
tous thorax, or barrel chest, occurs in subjects of hypertrophic em- 
physema. This type of thorax is increased in all of its diameters, 
but particularly in the antero-posterior, so that this diameter 
exceeds the transverse diameter of the chest. The chest on cross- 
section represents almost a circle, with the greatest degree of. en- 
largement near the middle of the sternum. Thus, the chest in sub- 
jects of this disease is thick, the shoulders are raised and bowed 
forward, while the Angle of Louis is very prominent. The normal 
dorsal curvature of the spinal column is accentuated, and, with the 
drooping shoulders, gives to the patient a stooping attitude. The 
ribs meet the sternum at an abnormally obtuse angle, producing an 
abnormally wide costal angle. The scapulae are closely applied 
to the back of the bony thorax. The entire thorax appears jto have 
become shortened and thickened. 

The emphysematous thorax is rigid, permitting but little expan- 
sion ; but in compensation for this deficiency, during respiration it 
rises and falls as one piece. Not infrequently there is visible re- 
traction of the lower interspaces during inspiration, while expira- 
tion is always prolonged. 

The Phthisical Thorax. — The phthisical thorax presents a marked 
contrast to the emphysematous chest. In the phthisical or para- 
lytic thorax the antero-posterior diameter is markedly decreased, 
so that the thorax is long, and flat, presenting a picture of ex- 
treme emaciation, owing largely to wasting of the pectoral and del- 
toid muscles. The clavicles are very prominent, contrasting 
markedly with the recession of the supra-clavicular and infra- 
clavicular regions above and below. 

The long, flat thorax is surmounted by an apparently abnor- 
mally long, tapering neck, in which the sterno-mastoid muscles 
and the larynx stand out prominently. 

The scapulae are very prominent, standing out upon the posterior 
thoracic surface like wings, leading to the name "Alar Thorax 7 ' 
sometimes applied to this type of chest. 

The ribs pursue a very oblique course downward from the spinal 
column and bend sharply upward again to meet the sternum, pro- 
ducing a very acute costal angle. The intercostal spaces are wid- 
ened. 

The Rachitic Thorax. — Rickets is accompanied by a character- 



[NSPECTION OF BESPIBATOEY ORGANS 



41 




Fig. 20. — Emphysemic chest. (Front viewO With asthma, emphysema invariably 
develops. If the tissues of the alveoli are more resistant than those of the bronchi, 
asthma may become more permanent than emphysema; the reverse may also be the case. 
If asthma endures for years, however, there is sure to be more or less permanent 
emphysema. In an emphysemic chest the sternum is high, and antero-posterior diameter 
exceeds the lateral, and the ribs have a more nearly horizontal course than usually obtains. 
(From Brown.) 



42 



PHYSICAL DIAGNOSIS 




Fig. 21. — Emphysemic chest. (Lateral view.) The sternum and anterior part of the chest 
have been forced into the position of extreme inspiration. (From Brown.) 



IXSJ'IXTION OF RESPIRATORY ORGANS 



43 



istic deformity of the thorax. In this type of thorax the antero- 
posterior diameter is increased, while the transverse diameter is 
decreased by a lateral compression of the soft ribs, causing the 
sternum to jut forward and become uncommonly prominent. A 
cross-section of the rachitic chest shows a marked increase in the 
antero-posterior diameter with an actual decrease in the trans- 
verse diameter of the thorax. 




Fig. 22. — Transverse section of emphysematous thorax. (Redrawn from Gee.) 





Fig. 



23. — Lateral contour of phthisical 
thorax. 



Fig. 24. — Lateral contour of emphysematous 
thorax. 



At the junction of the ribs with their costal cartilages the 
rachitic thorax presents a series of nodular spellings, due to 
swelling of the osteo-cartilaginous junctional tissues, the rachitic 
rosary. As a result of the lateral compression of the thorax the 
costal angle is abnormally acute. It is not uncommon to find the 
lower ribs anteriorlv flaring outward. 



44 



PHYSICAL DIAGNOSIS 



Various kinds of spinal curvature occur with the rachitic thorax, 
as kyphosis, lordosis, or scoliosis. 

The rachitic chest is not significant of any disease of the respira- 
tory organs; but the compressed thorax is too small for the lungs 
to properly expand and develop and hence it predisposes to dis- 
ease of the organs of respiration. 

Harrison's Sulcus. — Harrison's Sulcus is a depression or groove 
extending upon either side of the thorax from the ensiform proc- 
ess downward and outward toward the axillary regions. It is often 
a sign of early rickets; it almost invariably accompanies the 
rachitic thorax and it is also caused in early life by obstructive 




Fig. 25, — Phthisical chest. A, anterior view; B, lateral view; C, posterior view. 
(From Pottenger.) 



lesions of the upper air passages, in which event it is to be attrib- 
uted to the external atmospheric pressure pressing upon the soft 
ribs which are not supported by full inflation of the lungs. The 
deformity is particularly common in negroes. 

The Pigeon Breast (Keel Breast). — In this type of thoracic de- 
formity the ribs are compressed and straightened in front of their 
angles, causing the sternum to jut forward and become unduly 
prominent. On cross-section the thorax is roughly triangular. The 
anterior portion of the thoracic cavity is encroached upon by the 
incurvation of the ribs, while the posterior portion of the cavity 



ENSPECTION OF RESPIRATORY ORGANS 45 

is compensatorily voluminous. Harrison's Sulcus is often present 
upon the surface of the chest. 

The pigeon breast occurs most frequently in cases of advanced 
rickets ; but it may also be caused by the paroxysms of pertussis, or 
by greatly hypertrophied tonsils in early life. 




Fig. 26.— Phthisical thorax- 





Fig. 27. — Transverse section rachitic thorax. 
(, Redrawn from Gee.) 



Fig. 



28. — Transverse section of pigeon 
breast. t, Redrawn from Gee.) 



46 PHYSICAL DIAGNOSIS 

The Funnel Chest. — In this type of thoracic deformity the lower 
end of the sternnm is depressed, the hollow or depression occasion- 
ally extending as high as the third rib. The funnel-chest is in some 
instances congenital ; it has been noted in connection with rickets ; 
and it sometimes develops as the result of an occupation which re- 
quires an instrument to be held constantly against the lower por- 
tion of the sternum. Thus, the deformity has been noted in cob- 
blers, resulting from the continued pressure of the last. The fun- 
nel-chest is not a sign of pulmonary disease ; but, by decreasing the 
capacity of the thorax, predisposes to disease of the broncho-pul- 
monary system. 

UNI-LATERAL DEFORMITIES OF THE THORAX 

Uni-lateral Enlargement, or bulging of one side of the thorax, 
is significant of fluid or gas in the pleural cavity or of intra-thoracic 
neoplasm. Thus, uni-lateral bulging may signify the presence of 
pleurisy with effusion, hemothorax, pyopneumothorax, or hydro- 
pneumothorax. Similarly, uni-lateral enlargement may be signifi- 
cant of compensatory emphysema, arising as a result of vicarious 
distention of the lung to compensate for crippling of the opposite 
lung by fibrosis, in which case the shrinking of the opposite side of 
the chest adds materially to the apparent bulging of the emphy- 
sematous side. When the cause of the bulging is fluid, it is most 
pronounced in the lower portion of the thorax, the costal angle 
is rendered more obtuse, and the interspaces are* apt to bulge. The 
spinal column usually deviates toward the side of the effusion. 

Uni-lateral Contraction of the Thorax. — Uni-lateral contraction 
of the thorax is indicative of a diminution of the intra-thoracic con- 
tents on the affected side. Thus, it may be significant of collapse 
of the lung following bronchial obstruction, destruction of pul- 
monary tissue in the course of pulmonary tuberculosis, chronic 
fibrosis of the lung, chronic adhesive pleurisy, in which adhesions 
obliterate the pleural cavity and draw the chest wall inward, or of 
chronic pressure exerted upon the lung by pleurisy with effusion. 

All of these conditions are usually accompanied by compensa- 
tory emphysema of the opposite lung, thus causing accentuation 
of the disproportion between the two sides of the thorax. In addi- 
tion to the diseased side being smaller than is its fellow, the shoul- 
der of the affected side droops, and the spinal column is found 
bowed with its concavity toward the retracted side, while the in- 
terspaces on this side are narrowed or the ribs actually overlap. 



INSPECTION OF RESPIRATORY ORGANS 47 

LOCAL DEFORMITIES OF THE CHEST 

Local Enlargement. — Local enlargement of the thorax p< 
varying significance, depending upon the situation of the bulging. 
In the cardiac region local enlargement may be due to immense 
hypertrophy of the heart, pericarditis with effusion, pneumo- 
pericardium, aneurism of the ascending portion of the aorta, local- 
ized pleurisy with effusion, a mediastinal tumor pushing the heart 
forward, or an abscess of the lower portion of the sternum. 

A local enlargement over the left hypochondriac region points to 
splenic enlargement; while a similar enlargement over the right 
hypochondriac region points to enlargement of the liver due to cyst, 
abscess or simple enlargement, or to low right-sided pleurisy with 
effusion. 

Local Retraction of the supra-clavicular and infra-clavicular 
regions, with unduly prominent clavicles, usually point to apical 
pulmonary tuberculosis, cirrhosis of the lung, or to the traction of 
pleural adhesions. Local retractions over other regions of the 
thorax point to the presence of bronchiectatic or tuberculous cav- 
ities, or the traction of pleural or pericardial adhesions. 

RESPIRATORY MOVEMENTS OF THE THORAX 

The respiratory movements of the thorax comprise an inspira- 
tory excursion and an expiratory recession, the two being followed 
by a slight pause. The inspiratory movement is an active process, 
initiated by muscular contraction, whereas the expiratory reces- 
sion is a passive process, the chest collapsing with the relief of the 
muscular contraction. Of the two movements the expiratory reces- 
sion is of longer duration than is the inspiratory excursion. 

The frequency of the respirations in health varies with the age 
of the subject. In the healthy adult the number varies from 14 to 
18 per minute, being slightly more rapid in women than in men. 
In the newly born the respiratory rate is -44 per minute, while at 
five years of age it is 26 per minute. 

The character of the respiratory movement differs in the two 
sexes. Thus, in women the movements of the thorax are much 
more conspicuous than are those of the abdomen, the costal type 
of respiration. In the adult male, on the contrary, the abdominal 
muscles play quite a part in the respiratory movements, the costo- 
abdominal type of respiration. 



48 



PHYSICAL DIAGNOSIS 



However, exaggeration of either the costal or costo-abdominal 
type of respiration possesses diagnostic significance, and is patho- 
logical. Thus, purely costal respiration may be caused by im- 
mobilization of the diaphragm by paralysis or sub-diaphragmatic 
pressure due to ascites, abdominal tumor, peritonitis or tym- 
panites. Similarly, exaggerated or purely abdominal respiration 




Fig. 29. — Illustrating the movements of the diaphragm and thoracic and abdominal 
walls, as well as the change in position of the intra-thoracic and intra-abdominal viscera, 
during respiration of the abdominal type. The movements are from the. solid lines on 
expiration to the broken lines on inspiration. (Pottenger, after Hasse.) 



points to disease in the thorax, as pulmonary tuberculosis, mas- 
sive pleurisy with effusion, massive pneumonia, scleroderma of the 
chest wall, premature calcification of the costal cartilages, or inhi- 
bition due to the pain of pleurodynia or fracture of a rib. 
Litten's Diaphragmatic Phenomenon. — During the movements of 



INSPECTION OF RESPIRATORY ORGANS 



49 



the thorax in normal respiration a phenomenon may be observed 
which is of great diagnostic significance in the analysis of morbid 
conditions arising within the chest or abdomen. This is an undula- 
tion or "shadow" which may be observed upon the chest wall dur- 
ing inspiration and expiration, and which has received the name 
Litten's diaphragmatic phenomenon. The undulation or "shadow" 




Fig. 30. — Showing the movements of the diaphragm and thoracic and abdominal walls, 
as well as the change in position of the intra-thoracic and intra-abdominal viscera, when 
combined thoracic and abdominal breathing are pronounced. The movements are from 
the solid lines on expiration to the broken lines of inspiration. (Pottenger, after Hasse.) 



is initiated by the movements of the diaphragm during the respira- 
tory movements of the thorax. During inspiration the diaphragm, 
which at the completion of expiration is closely apposed to the 
thoracic wall in its lower portion, becomes separated from the 
thoracic parietes in its descent. This separation of the two appos- 



50 



PHYSICAL DIAGNOSIS 



ing surfaces during inspiration causes a slight undulation or 
"shadow" to pass down the anterior, lateral, and dorsal surfaces 
of the thorax from the seventh to the tenth rib. During expiration, 
as the diaphragm adapts itself again to the chest wall, there is 
an ascending undulation, which, however, is not as readily per- 
ceptible as is the descending shadow which occurs during inspira- 
tion. 

To elicit Litten's phenomenon the patient should be placed in 
the dorsal posture on a bed or table with the head slightly ele- 
vated and the arms stretched above the head, with the feet or head 
turned toward the source of light, in such position that the light 
falls obliquely upon the side under observation. The examiner 
should stand several feet from the patient with his back to the 



~PoSf^'of* 0JT Z>/'*/0JtrAjt/TT a* £fff of £*/"''** tr^t. 



7M*___ 




#/Ar 



Fig. 31. — Basis of Litten's phenomenon. (From Cabot.) 



light. Under these circumstances in a normal chest the shadow 
will be perceived to descend for the space of two inches or more 
during inspiration, and can usually be observed to ascend during 
expiration. 

Litten's Shadow is a normal phenomenon. Interference with or 
abolition of, the shadow points to a pathologic condition in the 
thorax or abdomen, which inhibits the free movement of the dia- 
phragm. In the thorax it may signify pneumothorax, pneumonia, 
hypertrophic emphysema, pleurisy with effusion, adhesions be- 
tween the pleura and the chest wall, intrathoracic neoplasm, or 
pulmonary tuberculosis. Of intra-abdominal conditions it may 
be indicative of upward displacement if the diaphragm by an en- 
larged liver or spleen, ascites, large abdominal tumor, or sub- 
phrenic abscess. 



IN- 1 MICTION OF RESPIRATORY ORGANS 51 

Pathologic Respiratory Variations 

Rapid Respiration (Polypnea). — Simple increase in the fre- 
quency of the respiratory movements of the thorax is observed after 
exercise and during strong emotion. It is also observed in pul- 
monary lesions which decrease the air space, as in the consolida- 
tions of tuberculosis and pneumonia ; in diminution of the intra- 
thoracic capacity by sub-phrenic pressure due to ascites or ab- 
dominal tumor, as well as mediastinal tumors compressing the 
lungs; in inflammations of the peritoneum; in congestion and 
edema of the lungs: and during the course of diabetes and uremia. 

Slow Respiration (Oligopnea). — Slow respiratory movements, 
the rate falling beloAv fourteen respirations in the minute, are ob- 
served during coma and collapse, and in cerebral pressure from 
tumor, apoplexy, abscess, or meningitis. The respiratory move- 
ments are also slowed during the course of infectious diseases 
associated with mental torpor. 

Prolonged Inspiration. — Inspiration is unduly prolonged in 
cases of tracheal and laryngeal obstruction from any cause. The 
interspaces over the lower portions of the chest are apt to be 
retracted during the inspiratory effort. 

Prolonged Expiration. — In hypertrophic emphysema and bron- 
chial asthma the expiratory phase of respiration is prolonged, 
the muscles of respiration being called into play in the effort to 
expel the air from the lungs, substituting an active for a passive 
process. 

Stertorous Respiration (Snoring Breathing). — This type of res- 
piration is noted in the presence of large adenoid vegetations in the 
naso-pharynx, chronic tonsillar hypertrophy, quinsy, postpharyn- 
geal abscess, in paralysis of the palate, and during the coma of 
apoplexy, uremia, or diabetes. 

Stridulous Respiration (Hissing Breathing'). — Stridulous res- 
piration is usually a sign of tracheal and laryngeal stenosis by 
tumors or foreign bodies. It may be produced by pressure upon 
these structures by enlarged glands, or an excessively hyper- 
trophied heart. It also occurs in spasm and edema of the glottis, 
which may develop in connection with syphilis or tuberculosis 
of the larynx, during diphtheria, acute laryngitis, or as a compli- 
cation of one of the acute infectious diseases. Stridor also occurs 
during an attack of laryngismus stridulus, and during the par- 
oxysms of pertussis, the stridor in these instances being most pro- 
nounced or entirely confined to inspiration. 



52 PHYSICAL DIAGNOSIS 

Cheyne-Stokes Respiration. — Cheyne-Stokes breathing is a type 
of respiration in which, following a period of apnea, the respira- 
tions become progressively deeper nntil a maximum depth is at- 
tained, whereupon they gradually become more shallow and finally 
terminate in another apneic period. The period of apnea lasts 
from ten to twelve seconds, and during this time the patient is 
likely to become unconscious. This type of respiration may persist 
for a few days or for several months, and is of grave prognostic 
significance. It is often a sign of impending dissolution. Cheyne- 
Stokes respiration is particularly associated with cerebro-spinal 
meningitis, apoplexy, brain tumor, the coma of uremia and dia- 
betes, and with tuberculous meningitis; more rarely with fatty 
heart and valvular disease of the heart; and very rarely develops 
during typhoid fever and pneumonia. 

Dyspnea. — Dyspnea, difficult or labored breathing, is recog- 
nized clinically by the increased frequency of the thoracic ex- 
cursions and by the participation of the accessory muscles of 
respiration in these movements. Dyspnea may exist in varying 



wvvAw, 




Fig. 32. — Cheyne-Stokes respiration. (From Cabot.) 

grades, ranging from a slight increase in the frequency of the 
respirations to extreme difficulty accompanied by blueness of the 
lips and finger-tips (cyanosis). 

The dyspnea may be limited to inspiration, as when the air 
passages are obstructed by a foreign body, or subjected to exter- 
nal pressure by a tumor, aneurism, or enlarged gland ; or, on the 
contrary the difficulty may only involve expiration, as is observed 
in hypertrophic emphysema and asthma. More frequently, how- 
ever, both phases of the respiratory cycle are involved. 

The causes of dyspnea are varied. Thus, dyspnea may be an 
expression of a diminution of the air space in the lungs by the 
consolidations of pulmonary tuberculosis or pneumonia; or of 
external compression of the lung by a pleural effusion or intra- 
thoracic neoplasm. 

Dyspnea may be caused by circulatory disturbances of the lungs. 
If a tumor obstructs the free return of blood from the lungs to the 
right heart, pulmonary congestion or edema occurs, leading to 
dyspnea. More frequently, however, it is in valvular lesions of 



INSPECTION OF INSPIRATORY ORGANS 53 

the heart, which permit the blood to accumulate in the pulmonary 
circulation, that dyspnea referable to circulatory disturbances of 
the lungs is observed. 

Diseases of the blood, associated with a diminution in the amount 
of hemoglobin or oxygen-carrying power of the blood as in chlo- 
roris, pernicious anemia, and the secondary anemias, occasion 
dyspnea. 

Many acute infectious diseases associated with toxemia and 
fever produce a dyspnea arising from the action of circulating 
toxins upon the respiratory centers. 

Orthopnea is an extreme grade of dyspnea in which the patient 
is able to breathe only in the erect or sitting posture. It is ob- 
served in asthmatic attacks and in regurgitant heart lesions. 



ABNORMALITIES OF THORACIC EXPANSION 

Abnormalities in the degree of expansion of the thorax may be 
bi-lateral, or uni-lateral, or circumscribed to certain areas of the 
surface of the thorax. 

Bi-lateral Changes 

Increased General Expansion of both sides of the thorax is 
observed following active physical exertion and during emotional 
states, without possessing pathologic significance. It is also ob- 
served in hypertrophic emphysema, during asthmatic attacks, and 
hysteria, when it has diagnostic significance. 

Decreased General Expansion of both sides of the thorax occurs 
as a result of general muscular weakness, atrophic emphysema, 
bi-lateral pleurisy with effusion, paralysis of the respiratory mus- 
cles, obstruction of the upper respiratory tract, or from the pain 
of pleurodynia or intercostal neuralgia. 

Uni-lateral Changes 

Increased Expansion of One Side of the thorax occurs when 
one lung must compensate for a crippling of the opposite lung. 
Thus, in cirrhosis of the lung the opposite lung expands vicariously 
as a result of compensatory ephysema causing an increase in the 
expansion of the sound side of the thorax. 

Diminution in the Expansion of One Side of the Thorax 
or uni-lateral diminution in the expansion of the chest, results 
from diminution of air space in the lung of that side, which may 



54 PHYSICAL DIAGNOSIS 

signify the consolidation of tuberculosis or pneumonia, or the 
pressure of a pleurisy with effusion, or a crippling of the lung 
by pleural adhesions. 

Local Changes 

Local Increase in Expansion of the thorax is usually observed 
in the supra-clavicular regions in cases of hypertrophic emphy- 
sema, affecting chiefly the apices of the lungs. 

Local Decrease in Expansion of the thorax often occurs in 
the supra-clavicular and infra-clavicular regions owing to apical 
tuberculosis. Local decrease is noted in other regions of the thorax 
when pleural adhesions bind the lung to the chest wall, the result 
of local pleurisies. 

Wavy Expansion of the chest is sometimes encountered in con- 
nection with lobar pneumonia, when different areas of the chest 
appear to expand in an irregular and uneven manner, one por- 
tion filling or expanding before other portions. 

Localized Areas of Pulsation. — Local areas of pulsation upon 
the thoracic surface possess various significance, depending upon 
the locality in which they are found. Thus, a pulsation near the 
base of the heart usually points to aneurism of the aortic arch. 
A pulsation arising on the left side of the thorax between the 
second and sixth ribs is frequently a sign of pulsating pleurisy. 
A pulsation over the low r er left lung posteriorly, below the left 
scapula, may signify a pulmonary cavity containing fluid, to which 
the impact of the heart is transmitted during systole. A circum- 
scribed pulsation in the lower portions of the chest anteriorly is 
often due to empyema necessitatis, in which event the chest wall 
is apt to be edematous or to present a localized area of discolor- 
ation. 



CHAPTER III 

PALPATION 

Object and Technic. — Palpation is employed in physical diag- 
nosis to confirm the findings of inspection as to the shape and size 
of the thorax, the respiratory movements and degree of expansion 
of the chest; and to detect slight deficiencies of expansion which 
are so slight as to escape detection during inspection. Palpation 
of the thorax also reveals the presence of certain vibrations 
(fremitus) arising within the chest. It also reveals the degree 
of resistance of lesions within the thorax, as also tenderness upon 
pressure, fluctuation, and local pulsations. 

As commonly employed, palpation consists in applying the 
palms of the hands to the surface of the thorax for the purpose 
of appreciating and analyzing tactile impressions conveyed to 
the palpating hand. In examination of the anterior, posterior, 
and lateral regions of the thorax the entire palm is placed flat 
upon the thoracic wall, while in palpating the supra- and infra- 
clavicular regions, the finger tips are often employed alone. Cer- 
tain clinicians prefer to employ the ulnar border of the hand in 
preference to the palm in palpation; but it seems unlikely that 
the tactile sensations appreciated by this portion of the hand 
could be as acute as those which can be detected by the more 
sensitive palms. During palpation of the thorax the clothing- 
should be removed to the waist so that no fabric may intervene 
between the palms of the examiner and the thorax of the sub- 
ject. As in all physical examinations the patient should assume 
an easy and natural position. 

In testing the expansion of the apices of the lungs the examiner 
should stand behind the patient and with the index and middle 
fingers in the supra- and infra-clavicular spaces respectively 
gauge the degree of expansion of the apex during full inspira- 
tion. To detect deficient expansion of the lateral regions of the 
chest the examiner should stand facing the patient and apply the 
two hands to the lower portions of the thorax. To test the an- 
teroposterior expansion he should stand beside the patient, 

55 



56 



PHYSICAL DIAGNOSIS 



and place one hand on the sternum and the other between the 
scapulae and note the degree of expansion during quiet and full 
inspiration. 




Fig. 33. — Palpation of anterior thoracic 
surface. 



Fig. 34. — Ulnar palpation of thorax. 




Fig. 35. — Palpation of upper anterior thorax. Fig.36.- — Palpation of pulmonary apices. 



Palpation, to be serviceable, must be systematic, the entire 
surface of the thorax being palpated and corresponding regions 
upon the two sides compared. Hasty, purposeless palpation leads 
to erroneous conclusions. 



PALPATION OF RKSPIRATORY ORGANS 



57 




Fig. 37. — Illustrating the method of detecting lagging at the apices. (From Pottenger.) 




Fig. 38. — Illustrating the method of detecting lagging at the base. The hands should 
be laid gently on the chest so as not to interfere with the normal respiratory movements. 
Often a pressure no greater than one or two pounds will completelv check the move- 
ments of the ribs. (From Pottenger.) 



58 



PHYSICAL DIAGNOSIS 



THORACIC VIBRATIONS 

Vocal Fremitus. — Vocal fremitus is a palpable vibration which 
is conveyed to the palpating hand when applied to the surface of 
the thorax while the patient speaks. The vibrations originate in 
the vocal cords and are transmitted downward by the air col- 
umns of the trachea and bronchi and thence by the pulmonary 
parenchyma and chest wall to the hand of the examiner. Vocal 
fremitus is a normal physiologic phenomenon. 

The intensity of the vibrations varies with the quality of the 
subject's voice, being more intense in men with coarse deep 







).; 


wm 


9 


.) 




. is AM, v 



Fig. 39. — Normal variation of vocal 
fremitus. 



Fig. 40. — Normal variation of vocal 
fremitus. 



voices than in women and children, whose voices are finer and 
less coarse. Similarly, the vibrations are more intense in thin 
chested individuals than they are in a subject with a thick chest 
with well developed musculature. 

There are normal regional variations in the intensity with 
which the vocal fremitus is transmitted to the palpating hand. 
Thus, the fremitus is most intense immediately over the trachea. 
It is more intense over the infra-clavicular and mammary re- 
gions than it is. over the lower regions of the thorax, becoming 
progressively more feeble as the palpating hand progresses down- 
ward. Its intensity is impaired over the scapulae posteriorly, 
and over the sternum anteriorly, as well as over the mammary 



PALPATION OF INSPIRATORY ORGANS 



59 




Fig. 41 A. — Sagittal section through the body showing the thickness of the soft 
structures covering the apex from which may be inferred the importance of the 
increased tone (spasm) or degeneration upon the findings on palpation, percussion, and 
auscultation. Anterior view. (.Pottenger, after Corning.) 



60 



PHYSICAL DIAGNOSIS 




M. trapezius. 
M. omohyoideus. 

M. supraspinatus. 

A. subclavia. 

Costa I. 

Clavlcula. 

Plane ok Manubrium Sterot. 

Scapula. 

M. subscapular!!!. 
Lobus superior pulmonis. 
Inc-isura interlobarls. 
M. pectoralis major. 

Lobus inedius pulmonis. 
Transthoracic Plane. 
Lobus inferior pulmonis. 
Diaphragm 



Costa VII. 
Liver. 

Trasspyloric Plane. 

Right kidney. 

Vesica fellea. (Gallbladder.; 
Flexura coli dextra. (Hepatic flfXUi'C 

Musculature of abdominal parietes. 

Colon transversum. 

Transtuber<tlar Plane, 

Intestinum (.tecum. 
M. gluteus inert ins. 
Intestinum tonne. 
M. iliacus. 

M. gluteus minimus. 
Os coxie. 



Caput femoiis. 

M. gluteus maxinius. 

Plank of (Symphysis. Ossivm 

M. iliopsoas. 
V. foinoralis. 



Fig. 415. — Section through body 6 cm. to the right of the median plane, view from 
the right. Showing the importance of the soft tissues as influencing physical examina- 
tion of different areas of the chest. (Pottenger, after Berry.) 



PALPATION OF KKSIMKATORY OKCA.vs 



61 




Bapnfa. 

A. MbckTf*. 

V. Rultlavia. 

CUvlcuU. 

PLANE OK MAKtBRmt STFP.lfT. 

Lobus superior pulmonis. 



Pericardium. 
Ventriculus sinister. 
Tr.Ay*THimA<-ic Plate. 

T>bu« inferior pulmonic 



Para cardiaca ventriculi. (Stomach.) 
OUndula suprarenalis. 
Left kidney. 

Corpus pancreatic 

binrruiH Pi at 

Pars pyloric* ventriculi. (Stomach./ 
Flexura duudenojejunalis. 



it. sacrospinal!*. (Erector spin*. 



• r insrersus lumbar vertebra. 
M. psoas major. 



Intestinnm tenue. 

Musculature of abdominal parietes. 

TRANSTl RERCILAR PLAXE. 

Pars lateralis ossis sacri. 
A. iliaca communis sinistra. 

V. iliaca communis sinistra. 

Intestinuin tenue. 

M. piriformis. 

A. iliaca externa sinistra. 

Ramus superior ossis pubis. 

M. obturator Interna*. 

Pl.ASK UF SVWHYfeIN (KmIM PvBB. 

Meuihranaobtamturi i. 

M. obturator externus. 

M. gluteus maxiuius. 

Ramus inferior Os-is ischii. 

Adductor musculature. 



Fig. 41 C. — Section through body 6 cm. to the left of the median plane viewed from 
the right. Showing the importance of the soft tissues as influencing physical examina- 
tion of different areas of the chest. (Pottenger, after Berry.) 



62 PHYSICAL DIAGNOSIS 

gland in the female subject. Moreover, vocal fremitus is more- 
intense over the right side of the thorax than upon the left 
side, because the right bronchus is larger than the left, occupies- 
a position slightly nearer to the anterior chest wall than does the 
left, and the eparterial bronchus, which is given off to the upper- 
lobe of the right lung, leaves the trachea at a point nearer the 
larynx. 

In eliciting vocal fremitus the examiner places the palms of 
the hands flat upon the thorax while the patient is directed to 
count "One, two, three," or to repeat the words "ninety-nine," 
the examiner meanwhile noting the intensity with which the- 
vibrations are transmitted to the palpating hand. 

Pathologic Variations. — Certain pathologic variations in the 
intensity of vocal fremitus are encountered in the investigation 
of morbid conditions arising within the respiratory organs. 
Thus, its intensity may be increased, decreased, or the fremitus, 
may be absent, as a result of different diseases of the lung, pleura, 
or air passages. 

Increased Vocal Fremitus. — The intensity of the voice vibra- 
tions is increased or exaggerated in those conditions in which 
the lung is rendered more solid and in which the air content of 
the tissue is reduced. That is, in all cases in which the air con- 
tent is diminished by consolidation or pulmonary compression. 
This is because the vibrations are more readily transmitted by a 
continuous solid medium than by the normal pulmonary tissue 
in which the solid structure is interrupted by air-containing^ 
spaces. Hence, vocal fremitus is found exaggerated in the pres 
ence of the consolidations of pneumonia and tuberculosis and in 
the presence of a tumor of the lung or pleura. It is also in- 
creased over tuberculous and bronchiectatic cavities which have 
an open communication with the bronchial system. These cav- 
ities act as resonating chambers for the vocal vibrations. 

Diminished Vocal Fremitus. — When the lung is separated from 
contact with the chest wall by a pleural effusion or a collection 
of gas or air in the pleural cavity as occurs in pneumothorax, 
the vocal fremitus is diminished. Its intensity is also diminished 
in hypertrophic and compensatory emphysema, owing to the 
rarefaction of the pulmonary tissues by the increased air 
content. 

Absence of Vocal Fremitus. — Vocal fremitus is absent over a. 
pulmonary cavity containing fluid. It is also absent over exten- 
sive pleural effusions, and over areas of the lung in which the 



PALPATION OF RESPIRATORY ORGAN- 63 

bronchus to the part has become obstructed from any cause. Ex- 
cessive pleural thickening will abolish vocal fremitus. 

Rhoncal Fremitus. — The term rhoncal fremitus is applied 
to the vibrations which are produced by the passage of air 
through mucus, pus, or blood in the bronchial tubes, the vibra- 
tions thus produced becoming appreciable to the palpating hand. 
Such a fremitus or vibration is encountered during the course 
of acute bronchitis, asthmatic attacks, in pulmonary tubercu- 
losis, and in all catarrhal inflammations of the bronchial tubes. 

These vibrations are occasionally referred to as rhonchi and 
are classified as large and small, as they arise in the larger or 
the smaller bronchial tubes respectively. Rhonchal fremitus is 
best demonstrated in children, whose chest walls are thin and 
resilient. 

Friction Fremitus. — When the pleura becomes inflamed there 
is a palpable vibration caused by the rubbing together of the 
roughened surfaces of this membrane. It is demonstrable dur- 
ing inspiration, being usually most intense in the lower axillary 
region. It is a significant and pathognomonic sign of fibrinous 
and sero-fibrinous pleurisy. In the latter disease the friction 
fremitus is present prior to the development of the effusion; it 
disappears during the effusion; and it recurs later with the ab- 
sorption of the fluid. 

Tussile Fremitus.— Tussile or Tussive Fremitus is a palpable 
vibration produced upon coughing. It does not as a rule possess 
great diagnostic significance and is not frequently elicited dur- 
ing routine examinations; but it is of service in dealing with 
patients the subjects of aphonia from any cause, when it is not 
possible to elicit vocal fremitus. 

Succussion Fremitus. — Succussion fremitus is a palpable vibra- 
tion produced when a patient whose pleural cavity contains air 
and fluid is suddenly jarred or shaken. The impact of the fluid 
will be felt against the palpating hand under these circum- 
stances. Large pulmonary cavities will give the vibration if 
they contain air and fluid. However, the sign is more frequently 
elicited in hydro- and pyo-pneumotliorax, and rarely with pleu- 
risy with effusion. 

Crepitus. — In cases of surgical emphysema, when the subcu- 
taneous tissues of the thorax contain beads of air, a fine crepita- 
tion or crepitus is often demonstrable upon palpating over the 
region with the finger-tips. 

Tenderness and Pain on Pressure.— In disease of the pleura or 



64 PHYSICAL DIAGNOSIS 

disease of the lung complicated with pleurisy, palpation often 
yields tenderness. The pain under these circumstances is elicited 
and is also defined by palpation of the intercostal spaces with the 
finger-tips. Pain elicited in this manner is suggestive of fibrin- 
ous pleurisy. Similarly, pain is elicited in intercostal neural- 
gia, pleurodynia, and in fracture or caries of a rib. 

Local Pulsations. — The pulsation of a Pulsating Empyema or. of 
aortic aneurism, or of a pulmonary cavity containing fluid and 
situated adjacent to the heart, the impact of the heart being 
transmitted to the fluid of the cavity, may be demonstrated by 
palpation. 

Increased Resistance. — Upon palpating the intercostal spaces 
over a pleural effusion, over the consolidation of pneumonia or 
tuberculosis, and in cases of excessive thickening of the pleura, 
a sense of increased resistance is appreciated by the palpating 
fingers. 

Fluctuation. — Fluctuation can only occasionally be elicited in 
affections of the thoracic viscera. However, in the case of em- 
pyema necessitatis about to rupture, pitting upon pressure or 
actual fluctuation can occasionally be demonstrated. It is 
elicited by placing the palpating hand over the suspected area 
and forcibly striking the opposite side of the thorax with the 
free hand. 



CHAPTER IV 

PERCUSSION 

Objects and Technic. — Percussion is employed in the study 
of disease of the respiratory organs for the purpose of eliciting 
sounds normal to the pulmonary parenchyma and sounds only 
arising- in diseased states of these organs; to determine the 
borders of the intra-thoracic organs; and also to note the degree 
of resistance offered to the percussion stroke by the tissues un- 
der examination. 

Percussion, as commonly practiced, consists in striking the 
surface of the area under examination with a view primarily to 
eliciting sound, and secondarily for the determination of the de- 
gree of resistance offered to the percussion blow. During this 
maneuver the percussion blow may be directed with the finger 
or with a special percussion hammer, and either directly upon 
the part under examination, or upon an intervening medium, 
usually a finger of the opposite hand of the examiner, or in 
other instances plates of metal, ivory, or glass. The instrument 
with which the blow is struck, finger or hammer, is termed the 
plexor; the intervening medium, finger or plate, is termed the 
pleximeter. When an intervening medium or pleximeter is em- 
ployed, the percussion is termed mediate percussion; whereas when 
no such intervening instrument is present, but the blow is directed 
directly upon the part which is under examination, the percussion 
is termed immediate percussion. 

Immediate Percussion.— In this form of percussion the plexim- 
eter is dispensed with, the blow being struck directly upon the 
part under examination. Immediate percussion is little employed 
except in tapping the clavicles to determine the presence of a 
possible consolidation of the apices of the lungs; or in slapping 
the two sides of the thorax alternately with the palm of the 
hand to determine the presence of dullness over a relatively 
large area, usually at the bases posteriorly. 

Mediate Percussion. — In practicing mediate percussion, the 
left hand of the examiner is placed palm down upon the area 
under examination, the percussion blow being directed upon the 

65 



66 



PHYSICAL DIAGNOSIS 



base of the nail or the second phalanx of the middle finger of 
this hand. To obtain the best results it is essential that the 
pleximeter finger be applied firmly and evenly upon the part; 
that the percussion blow be delivered quickly and in a vertical 
direction; that the plexor finger be raised at once and not per- 




Fig. 42. — Percussion of pulmonary apices. 




Fig. 43. — Percussion of lateral thoracic region. Fig. 44. — Percussion of posterior thorax. 



mitted to remain in contact AA T ith the pleximeter; that the per- 
cussion blow be delivered entirely by a wrist movement, the fore- 
arm not participating; and that the blows be delivered with uni- 
form intensity. In practicing percussion only a few strokes 
should be used in a given region. As much information can be 



PFROL'SSION OF RESPIRATORY ORGANS 



67 



obtained by four or five strokes properly directed as by a greater 
number, which tend to deaden the nicety of the auditory appre- 
ciation of the sounds elicited. In comparing the sound elicited 
upon the two sides of the chest exactly corresponding points 

should be selected on either side, and the percussion strokes 
should be directed with the same force upon each side. 




Fig. 45.4. 




Fig. 455. 

Fig. 45. — Illustrating a common error in percussing the apices. A. Proper position. 
showing percussion of the apices while the patient's head is erect and tension removed 
from the sterno-cleido-mastoideus and other neck muscles. B. Wrong position, per- 
cussing same when the head is turned and bent over toward the opposite side, thus 
putting the sterno-cleido-mastoideus and other muscles on tension, thereby raising the 
pitch of the percussion note and increasing the resistance to the percussion finger. 
(From Pottenger.) 



68 



PHYSICAL DIAGNOSIS 



Force of the Percussion Stroke.— The force to be employed in 
percussion depends upon the thickness of the chest wall and 
upon the object of the examination. In thin chested individuals 
and in children little force is required to elicit a clear sound. 
In stout persons, on the contrary, with thick thoracic walls, a 
greater degree of force is required for the purpose. The degree 
of force employed also varies with the location of the lesion 
which it is desired to study. In outlining lesions near the sur- 
face of the chest superficial . percussion is employed, the stroke 
being light. In outlining deep lesions deep percussion, with heavy 
strokes must be employed. 

Palpatory Percussion. — This mode of percussion is practiced 
by striking the pleximeter with a pushing movement rather than 



\jHI 


Q 




n>h ~ : '": 



Fig. 46. — Auscultatory percussion. 



with a sharp stroke, as in ordinary mediate percussion, and al- 
lowing the plexor to remain for an instant upon the pleximeter. 

The chief object of this procedure is to determine the degree 
of resistance afforded by the underlying structures rather than 
the production of sound. 

Auscultatory Percussion. — This mode of percussion is employed 
for the purpose of marking out the borders of organs, tumors, or 
collections of fluid. In practicing auscultatory percussion the 
chest-piece of the stethoscope is placed over the organ or struc- 
ture to be outlined and retained in position by the patient or an 
assistant while the examiner, after first percussing near the bell 
of the instrument and fixing in his mind the quality of the note 
elicited, then percusses toward the instrument from several di- 



PERCUSSION OF RESPIRATORY ORGANS 69 

rections upon the surface of the chest in the vicinity. The 
points at which the percussion note is observed to change are 
marked on the skin with a dermographic pencil; and, when con- 
nected by a line drawn through each of them, will represent the 
limits of the organ or structure under examination. As will be 
noted later, in percussing toward solid structures within the 
chest which are overlaid by lung tissue, the quality of the note 
is observed to undergo two changes. 

Attributes of the Percussion Sound. — Upon percussion of the 
surface of the chest sound is elicited, which possesses certain at- 
tributes or properties; namely, quality, pitch, intensity or volume, 
and duration. 

Quality. — Quality is the property or attribute by which a given 
sound is distinguished from a sound of different origin. It is by 
the quality of the sounds that the sound produced upon striking a 
piece of iron is distinguished from that produced upon striking a 
piece of wood. It is their quality which gives to the various sounds 
elicited upon percussion their individuality and their diagnostic 
significance. 

Pitch. — The pitch of a sound is determined by the rapidity of 
the vibrations which produce the sound. When the surface of 
the thorax overlying the lungs is struck the air content of the 
pulmonary alveoli is thrown into vibrations. Pitch may be high 
or low, depending upon the rapidity of these vibrations, rapid 
vibrations producing a sound of high pitch, while slow vibra- 
tions produce one of low pitch. The rate of the vibrations is 
in turn influenced by the size of the cavity containing the air 
and by the force of the percussion blow. 

Intensity. — Intensity, or volume, has reference to the loudness 
of the sound, this in turn depending upon the amplitude of the 
vibrations produced, the force of the percussion stroke, the 
thickness of the chest wall, and the amount of air in the area 
under examination. Thus, with heavy percussion over an area 
of lung containing much air and with a thin chest Avail, an in- 
tense sound is produced ; while a similar stroke over a region con- 
taining little air, overlaid by thick chest walls, would produce a 
sound much less intense. 

Duration. — The duration of the percussion sound or the length 
of the sound possesses less diagnostic significance than do the 
other attributes. In general it may be stated that the clearer 
the note and the higher the pitch, the shorter the duration; the 
duller the note and the lower the pitch, the longer the duration. 



70 PHYSICAL DIAGNOSIS 

Sense of Resistance. — Aside from eliciting sound percussion is 
employed to note the degree of resistance as appreciated by the 
pleximeter. In many instances the degree of resistance encoun- 
tered affords as valuable information as does the sound elicited ; 
and in instances where for any reason the sounds produced are 
not typical, it may be the sole guide of the examiner. An in- 
creased resistance to the percussion blow as appreciated by -the 
pleximeter indicates a decrease in the air content of the region 
under examination and increase in solid structure or the pres- 
ence of fluid. Thus, a high pitched note with well marked sense 
of resistance indicates that the air content is small, while the 
proportion of the solid material is excessive. 

THE NORMAL PERCUSSION SOUNDS 

The sound elicited by percussion of the normal chest is termed 
resonance, or normal vesicular resonance. The quality of this 
sound is distinctive and is only afforded by percussion of the 
normal pulmonary tissue containing its normal quota of air 
separated by the inter-alveolar septa. 

Kesonance in its greatest purity is obtained by percussion in 
the infra-clavicular and axillary regions, and at the bases pos- 
teriorly, below the angle of the scapula. In the supra-clavicular 
regions, upon percussing inward, the normal vesicular resonance 
of the pulmonary apices becomes mingled with the tympany of 
the adjacent trachea. In the mammary regions the mammary 
gland impairs the purity of the resonance, and upon percussion 
toward the sternum the osteal resonance of this bone blends with 
the normal vesicular resonance afforded by the pulmonary tissues. 
Also in the right mammary region in its lower portion the dullness 
of the liver blends with the normal vesicular resonance of the 
right lung ; while on the left side the dullness of the heart blends 
with the resonance of the left lung. In the right axillary region, 
in the lower portion, the dullness of the liver impairs the reso- 
nance of the lung; while in the lower portion of the left axillary 
region the resonance of the left lung is impaired by both the 
tympany of the stomach and the dullness of the spleen. In the 
supra-scapular and scapular regions the resonance is markedly de- 
creased by the intervention of the bony scapula overlaid by its 
muscles, while in the inter-scapular region and infra-scapular re- 
gions the resonance does not equal that of the anterior regions 
of the chest. 



PERCUSSION OP RESPIRATORY ORGANS 71 

The Normal Limits of Pulmonary Resonance. — The normal 
limits or boundaries of pulmonary resonance correspond prac- 
tically with the borders of the lungs anatomically, extending one 

to one and a half inches above the clavicle; as low as the sixth 
rib in the mid-clavicular line; the eighth rib in the mid-axillary 
line; and the tenth rib in the scapular line. 

Variations in the Limits of Pulmonary Resonance. — In broncho- 
pulmonary disease any lesion which increases the extent of the 
lung in any direction will cause a corresponding increase in the 
limits or boundaries of pulmonary resonance; and any lesion 
which decreases the extent of the lung in any direction produces 
a corresponding Limitation of the normal resonance to the extent 
of the lesion. It follows that in disease of the lung or pleura we 
may find the resonance generally increased or decreased in all 
directions, increased or decreased in certain directions; or in only 
one area of the lung. 

A General Increase of normal resonance in all directions, all 
of the borders of the lungs extending further than they normally 
should, is noted in subjects of hypertrophic emphysema, during 
asthmatic attacks, in sufferers with fibrinous bronchitis, and in 
dyspneic patients with uncompensated cardiac lesions. 

A General Decrease of pulmonary resonance, in which the 
borders of the lungs are generally retracted in all areas, is noted 
in atrophic emphysema, in which the lungs are greatly and sym- 
metrically shrunken and atrophied. 

Extension of Resonance at the Apices is practically only en- 
countered in hypertrophic emphysema chiefly affecting the upper 
portions of the lungs and during asthmatic attacks. 

Decreased Resonance at the Apices indicates apical tuber- 
culosis, apical pneumonia, chronic adhesive pleurisy, or pulmonary 
collapse from bronchial obstruction. In apical tuberculosis the 
resonance is apt to be decreased at both apices ; whereas in apical 
pneumonia or chronic adhesive pleurisy the retraction usually 
involves a single apex. 

Extended Resonance of the Anterior Borders of the lungs, so 
that they overlap and obscure the normal limits of the heart, is 
indicative of hypertrophic emphysema or bronchial asthma. 

Decreased Resonance of the Anterior Borders of one or both 
lungs is indicative of fibroid retraction of a lung from chronic in- 
terstitial pneumonia or fibroid phthisis, or displacement of the 
anterior border by pleural or pericardial effusion. In the case of 
fibroid retraction of the lung the cardiac impulse is diffuse, oc- 



72 



PHYSICAL DIAGNOSIS 




v • u 



10 "^ ,r. 





/" 






.- bo w 



fl o 
en dj 

£■§■§ 

G o 

11 u - 

> c^ 

<D en 

u 3 -m 



J3 re- 
bels 



a) to 



bc .. <u 

Mi 

bO^ *- 2 



PERCUSSION OF RESPIRATORY ORGANS 



73 





.~ to 



/ - 

- 7 K 

~ g"o 
X > 

- ■— u 
"* -- 

- B s 

ll J 

- - - 
a b — 

/ - — 

c — — 



J; 3 

o c = 



00 <u 

■ - id 






74 PHYSICAL DIAGNOSIS 

cupying a wide area in the second, third, and fourth interspaces ; 
whereas in pleural or pericardial effusion the impulse is displaced 
or invisible. 

Increased Eesonance of the Lower Borders of the lungs is 
part and parcel of the general extension of resonance accompanying 
hypertrophic emphysema or bronchial asthma. It may also occur 
with fibrinous bronchitis and uncompensated cardiac lesions. 

Decreased Resonance of the Lower Borders of one or both 
lungs points to fibroid retraction of the lung due to chronic inter- 
stitial pneumonia or fibroid phthisis; or to elevation of the dia- 
phragm due to paralysis of that muscle or to the sub-phrenic pres- 
sure of ascites, abdominal tumor, peritonitis, hepatic enlargement 
or abscess. In atelectasis the lower border of resonance is elevated. 

The Respiratory Excursion of the Lung. — In determining the 
respiratory excursion of the lung the lower borders of both 
lungs should be defined by percussion in the mid-clavicular, mid- 
axillary, and scapular lines, first during quiet respiration and 
then during forced respiration, the difference being noted. Usu- 
ally measuring approximately one inch, in certain diseases of 
the thorax or abdomen it may be diminished markedly. 

ABNORMAL PERCUSSION SOUNDS 

Impaired Resonance. — The percussion note shows slight im- 
pairment of resonance, not amounting to dullness, which is the 
next gradation, when there is only a moderate increase in the 
solid over the normal structure of the lung. Impaired resonance 
is elicited particularly in the early stages of pulmonary tuber- 
culosis at the apices of the lungs. 

Impaired resonance is also a sign of moderate pleural thicken- 
ing and incipient consolidation from any cause. It is the first 
step toward dullness, but is not so pronounced in its change of 
quality. 

Dullness. — As in impaired resonance, dullness indicates a de- 
crease in the air-content of the part and a corresponding in- 
crease in the solid elements of the area under examination. But 
the note is more materially changed than it is in impaired re- 
sonance. A dull note is elicited upon percussion in the presence 
of the consolidations of pneumonia and tuberculosis, infiltration 
of the lung with edema and hypostatic congestion, in carcinom- 
atous infiltration, in the presence of considerable pleural thick- 



PERCUSSION OF RESPIRATORY ORGANS 



75 





Fig. 49. — Dullness in apical pulmonary 
tuberculosis. 



Fig. 50. — Physical causes of change in 
percussion note. (Redrawn from Le Fevre.) 
/-.'. dullness on percussion; ;, deep dullness 
masked by intervening lung. 




Fig. 51. — Area of dullness in moderate 
pleural effusion. 



Fig. 52. — Grocco's sign in serofibrinous 
pleurisy. 



76 



PHYSICAL DIAGNOSIS 



ening, in the area of a lung which is compressed by a tumor, in 
atelectasis, and in pulmonary syphilis. 

Dullness localized to a special region is seen in pleurisy with 
effusion, owing to compression or condensation of the mediastinal 
structures and their deflection toward the side of the thorax 
opposite to the effusion. Thus, in pleurisy with effusion there is 
often a triangular area of para-vertebral dullness opposite the 
side of the effusion, at about the level of the 12th dorsal spine, 
which constitutes Grocco's sign of this disease. 

Flatness. — Flatness, or a percussion note which is entirely de- 





# J- 


to 

<• 








♦♦* 



%r 



Fig. 53. — Dullness in aortic aneurism. 



Fig. 54. — Schematic representation ot 
multiple areas of consolidation in broncho- 
pneumonia. 



void of resonance, is indicative of the entire absence of air from 
the area percussed. It is elicited by percussion over a consoli- 
dated lobe in fibrinous pneumonia, over a pleural effusion, a 
tumor of the lung or pleura, a greatly hypertrophied heart, a 
cirrhosed lung, a hydrothorax, or a pulmonary cavity filled with 
fluid. A deeply seated consolidation, overlaid by normal lung 
often fails to give dullness or flatness owing to compensatory 
emphysema of the intervening lung and requires a deep percus- 
sion to elicit dullness. 

Hyper-Resonance. — Hyper-resonance, or increased resonance, 



PERCUSSION OF RESPIRATORY ORGAN'S 



77 



is an abnormal clearness of the percussion sound, owing to an 
increase of the air content in the area percussed. Hyper-reso- 
nance may be bi-lateral, uni-lateral, or local. "When bi-lateral 
hyper-resonance is elicited it usually indicates hypertrophic em- 
physema; when uni-lateral, compensatory emphysema is the usual 
underlying cause; while localized hyper-resonance may be elicited 
over a small portion of a Lung which is the site of compensatory 
emphysema to compensate for an adjacent focus of consolidation. 
Such a localized area of hyper-resonance is often indicative of 




Fig. 55. —Changes in percussion note. 
( Redrawn from Le Fevre.) /, normal vesic- 
ular resonance; -', impaired resonance; 3, 
normal resonance on light percussion, im- 
paired resonance on strong percussion: 4, 
normal vesicular resonance; 5, dullness; 6, 
flatness. 




Fig. 56. — Percussion and auscultatory 
signs in pleurisy with effusion. (From But- 
ler.) 1 and 2, flatness on percussion, ab- 
sence of respiratory sounds; J, skodaic res- 
onance on percussion and puerile respira- 
tion. 



a deeply seated patch of consolidation, which requires deep per- 
cussion to indicate its presence. 

Skodaic Resonance is a variety of hyper-resonance, which is 
dependent upon relaxation of the pulmonary tissues, which are 
compressed by a solid tumor, an enlarged heart, or effusion in 
the pericardium or pleural cavity. Thus, skodaic resonance is 
elicited by percussion of the chest wall just above the level of a 
pleural effusion, or over the lung just adjacent to a greatly hy- 



78 



PHYSICAL DIAGNOSIS 



pertrophied heart or a large pericardial effusion, or over an area 
of the lung which is compressed by a neoplasm. 

Tympany. — Tympany represents the acme of hyper-resonance, 
percussion yielding in this instance a tympanitic or drum-like 
note. Its prototype is found upon percussion over the distended 
stomach. The significance of tympany is a pulmonary cavity 
with tense walls, the cavity containing air and possessing a free 
bronchial communication. A bi-lateral tympanitic note is oc- 
casionally demonstrable in the presence of hypertrophic em- 
physema, in which instance it is to be attributed to the many 
thin-walled sacs containing an excess of air. A similar note is 
sometimes elicited in the early stages of lobar-pneumonia, when 
it is due to temporary relaxation of the pulmonary tension. A 
tympanitic note is elicited over tuberculous and bronchiectatic 
cavities with patent bronchial outlet, and over a pneumothorax. 

SPECIAL SOUNDS 

Amphoric Resonance. — Amphoric resonance is a tympanitic 
note, with a clanging, echoing quality, which is produced by 
forcible percussion over a rather large, superficial cavity with 
tense walls and free bronchial outlet. It is heard typically in 
large bronchiectatic or tuberculous cavities, and in pneumothorax 
with a pulmonary fistula. To elicit the sound the percussion 



t?r«cjcSp*,Ji„ 



O'-tc/rcc/ P.J7 Soartt/ 

rBncA'a/ fes/°/r«t/osr 




Fig. 57. — Anatomic and pathologic basis of physical signs in percussion and auscultation 
of the thorax. (Redrawn from Butler.) 



stroke should be delivered *rather forcibly with the patient's 
mouth held open. 
The Cracked-Pot Sound (Money- Chink Resonance.) — The 

cracked-pot sound is a percussion note which resembles the 
sound produced by tapping the side of a cracked metal jar. The 
sound has also been compared to the muffled chink of coins, 
hence the name money-chink resonance, which is sometimes ap- 



PERCUSSION OF RKKl'IRATORY ORGAN'S 



79 



plied to it. The eracked-pot sound may be imitated by striking 
the clasped palms over the knee. To elicit the sound the pei-- 
cussion stroke should be delivered during expiration, with the 
patient's mouth open, the examiner's car meantime being held 
near the lips of the patient. 

The cracked-pot sound indicates a pulmonary cavity with free 
bronchial communication, or a pneumothorax Avith a communi- 
cating bronchial fistula. The cracked-pot sound may in rare 
instances be elicited by percussion above a pleural effusion or in 
pneumonia prior to consolidation. The mechanism of produc- 
tion of the sound seems to be the sudden expulsion of air from a 
cavity or area of the lung through a rather small opening. 

Williams' Tracheal Tone. — This name has been applied to a 
somewhat tympanitic note elicited upon percussion of an apical 




Fig. 58.- — Wintrich's interrupted change of sound. (.Redrawn from Da Costa.) 



consolidation, shrunken pulmonary apex, or pleural effusion, 
which instead of yielding dullness gives forth tympany conducted 
from the adjacent trachea. The note is elicited by rather forcible 
percussion in the supra- and infra-clavicular regions. 

Wintrich's Change of Sound. — Upon percussion over a cavity 
with a free bronchial communication, the note elicited is of 
low T er pitch when the patient's mouth is closed than when the 
mouth is open. This variation of the pitch of the percussion note 
under these two circumstances constitutes Wintrich's Change of 
Sound, a sign which should be sought for in all cases of suspected 
cavity formation. 

Interrupted Wintrich's Change of Sound. — This phenomenon 
consists in the alternate presence and absence of Wintrich's 
change of sound upon altering the posture of the patient. It is 



80 



PHYSICAL DIAGNOSIS 



indicative of a pulmonary cavity with free bronchial outlet, the 
cavity containing fluid, which so shifts with the change of the 
patient 's posture as to alternately close and leave unoccluded the 
bronchial outlet to the cavity. When the patient's posture is 
such that the bronchial communication is open or is above the 
level of the fluid, Wintrich's change of sound is demonstrable 
upon percussion; whereas when with the change of the patient's 
posture the fluid shifts so as to occlude the bronchial opening, 
the sound cannot be elicited upon percussion. 

Friedreich's Respiratory Change of Sound. — The percussion 
note elicited over a pulmonary cavity is of higher pitch at the 
completion of full inspiration than during expiration, owing to 
the increased tension of the walls of the cavity at this phase of 
the respiratory cycle, and because of widening of the glottis 




Fig. 59. — Gerhardt's sign. (Redrawn from Da Costa.) 



during inspiration. This respiratory alteration in the character 
of the percussion sound constitutes Friedreich's respiratory 
change of sound. 

Gerhardt's Change of Sound. — When the horizontal and ver- 
tical diameters of a pulmonary cavity with free bronchial out- 
let, the cavity containing fluid, are unequal, there is a change in 
the pitch of the percussion note elicited over the cavity with 
change in the posture of the patient. When the greatest di- 
ameter of the cavity is horizontal the percussion note is of lower 
pitch than it is when the greatest diameter is vertical, as a re- 
sult of the change in the relative positions of the air and fluid 
in the cavity. 

Biermer's Phenomenon. — This is a change of the percussion 



PERCUSSION OF RESPIRATORY ORGANS 



81 



note upon change of the patient's posture analogous to the 
change of pitch in Gerhardt's change of sound. Thus, in cases 
of hydro-pneumothorax the percussion note is of lower pitch 
when the patient is in the recumbent posture than it is when the 
patient assumes the upright position. 

G-airdner's Coin Test (Bell Tympany). — In cases of pneumo- 




Fig. 60. — Mechanism of Gardner's coin test. (Redrawn from Da Costa.) 



thorax, when the stethoscope is applied to the base of the chest 
posteriorly while an assistant percusses the front of the chest 
with two coins employed as pleximeter and plexor respectively, 
an echoing metallic ring is appreciated through the stethoscope, 
described as resembling the distant ring of a hammer upon an 
anvil. 



CHAPTER V 
AUSCULTATION 

Object and Technic. — Auscultation is the act of listening' to 
sounds arising within the thorax with the unaided ear, or with a 
special instrument, the stethoscope. When the unaided ear is 
employed it is termed immediate auscultation in contradistinction 
to instrumental auscultation, which is termed mediate auscultation. 
For obvious reasons the stethoscope with but few exceptions is 
preferable to the unaided ear; but the student of physical diag- 
nosis should become proficient in both methods of auscultation. 

Auscultation is employed in the study of sounds emanating 
from the intra-thoracic viscera and in the examination of certain 
vascular phenomena. 

Stethoscopes are termed mon-aural and bin-aural, as they are 
equipped with one or two ear pieces respectively. The mon- 
aural stethoscope is little employed at the present time, having 
given place to the bin-aural instrument. Stethophones have been 
employed in auscultation, the object of the instruments being to 
magnify the sounds; but their use is not advisable, as they are 
poor conductors of high pitched vibrations, and from a clinical 
standpoint the clearness and distinctness of the sounds is of 
more importance than is magnification of the intensity of the 
sounds. 

In the selection of a stethoscope care should be exercised to 
secure an instrument whose chest-piece or bell and tubing are 
sufficiently heavy to exclude all extraneous sounds, and whose 
ear-pieces fit snugly in the examiner's ears. 

In practicing mediate auscultation the chest-piece of the stetho- 
scope is applied firmly and evenly, but without exerting undue 
pressure upon the part under examination. The bell of the in- 
strument is retained in position with the forefinger and thumb 
of the hand of the examiner. No article of wearing apparel 
should intervene between the bell of the instrument and the 
surface of the thorax. During the examination of the respira- 
tory organs the examiner should note the character of the sounds 
produced during quiet, moderately deep, and forced inspiration, 
being ever on the alert for any deviation from the normal sounds. 

82 



AUSCULTATION OF RKSI'IRATORY ORGANS 



83 



The ear should be trained to disregard all extraneous noises, 
such as the friction produced by the rubbing together of the tubing 
of the instrument, and crepitations due to contact of the bell of 
the instrument with a hairy chest wall. This last annoying fea- 
ture may he eliminated by moistening the bell of the stethoscope 




Fig. 61. — Stethoscope. 




Fig. (>2. — Auscultation of thorax. 



before applying it to a hairy chest wall. The beginner in auscul- 
tation may find it difficult to separate the cardiac and pulmonary 
sounds ; but concentration and practice will enable one to disre- 
gard the one while studying the other. 



THE RESPIRATORY SOUNDS IN HEALTH 

Upon auscultation of the various regions of the normal thorax 
three types of respiration are noted; namely, bronchial, vesic- 
ular, and broncho-vesicular. 



84 



PHYSICAL DIAGNOSIS 




Fig. 63. — Normal areas of bronchial and broncho-vesicular breathing. Anterior view 

(From Butler.) 




Fig. 64. — Normal areas of bronchial and broncho-vesicular breathing. Posterior view. 

(From Butler.) 



AUSCULTATION OF RESPIRATORY ORGANS 85 

Bronchial Breathing". — Bronchial breathing is audible upon 
auscultation over the lower portion of the trachea and over the 
inter-scapular regions between the seventh cervical and the 
fourth dorsal vertebra'. The sound is loud and blowing or tubu- 
lar in quality, the two phases of the respiratory cycle being of 
equal length, though occasionally expiration is slightly pro- 
longed. Inspiration and expiration are separated by a distinct 
interval; and expiration is of slightly higher pitch than is the 
inspiratory sound. 

Bronchial breath sounds are produced by the vibrations which 
are set in motion in the inspired air as it passes through the 
glottis, these vibrations being transmitted downward chiefly by the 
air column in the trachea and bronchi, and partly by the walls of 
these passages. 

Vesicular Breathing'. — Upon auscultation in the infra-clavicu- 
lar and mammary regions anteriorly, in the axillary regions 
Laterally, and over the bases of the lungs posteriorly, the respira- 
tory sounds have a soft, breezy sound of low pitch, which is 
termed Vesicular Breathing. The sound possesses or consists of 
two murmurs, inspiratory and expiratory, which are separated 
by an almost imperceptible interval, the inspiratory murmur 
being maintained three times as long as is the expiratory phase. 
The sound of vesicular breathing has been aptly compared to 
that produced by the passage of a gentle wind through the leaves 
of a tree. 

Vesicular breathing is audible over portions of the lungs which 
are comparatively remote from the main bronchial tubes, the 
blowing sounds of the glottis being modified in their transmission 
through the lung, and are modified or mingled with the soft 
movements of the pulmonary tissues. Vesicular breathing is 
somewhat less intense over the scapulae posteriorly and over the 
mammae anteriorly in women. In the right infra-clavicular re- 
gion the expiratory phase is apt to be somewhat prolonged, owing 
to the closer proximity of the right bronchus to the anterior 
chest wall. 

Broncho-Vesicular Breathing. — This type of respiratory sound 
combines the qualities of bronchial and vesicular breathing. It is 
audible over those portions of the thorax where the larger bron- 
chial tubes are in fairly close proximity to the thoracic wall; but 
are nevertheless overlaid by air-containing pulmonary tissue. 
Broncho-vesicular breathing is normallv heard over the lower 



86 



PHYSICAL DIAGNOSIS 



portion of the manubrium sterni anteriorly, and over the inter- 
scapular region posteriorly at the level of the third dorsal 
vertebra. 

THE RESPIRATORY SOUNDS IN DISEASE 

Bronchial Breathing. — When bronchial breath sounds are de- 
tected in a region of the thorax where they are not normally 
audible, it usually points to consolidation, the solidification of 
the lung conducting the murmur from the large bronchi to the 
surface of the chest. Other factors which produce the same re- 
sult comprise pulmonary compression and collapse, hemorrhagic 
infarction, cirrhosis of the lung, enlarged bronchial glands, a tu- 
mor overlying a large bronchus, or a pulmonary cavity near the 
surface of the chest with a free bronchial communication. 

Bronchial breathing which is produced by a cavity with a 






Pecrer/'/ef t,y 




Fig. 65. — Anatomic and pathologic basis of physical signs in percussion and auscultation 
of the thorax. (Redrawn from Butler.) 



patent bronchial communication frequently has a peculiar hol- 
low quality engrafted upon it to which the term cavernous breath- 
ing is applied. In this type of bronchial respiration expiration is 
frequently of lower pitch than is inspiration. Simlarly a cavity 
with patent bronchial communication or a pneumothorax with an 
open bronchial fistula often gives rise to bronchial breathing of 
rather musical quality, closely simulating the sound generated by 
gently blowing across the mouth of an empty bottle, amphoric 
breathing. 

Vesicular Breathing. — In disease of the respiratory organs the 
intensity or rhythm of the normal vesicular murmur may be so 
altered as to possess diagnostic significance. 

Diminution in the intensity or entire abolition of the vesicular 
murmur may be encountered. Diminution in the intensity of the 



AUSCULTATION OF RESPIRATORY ORGANS 87 

murmur is normal in aged subjects and in subjects with very thick 
chest walls. The murmur is also diminished in painful diseases of 
the chest wall such as incipient pleurisy and pleurodynia, which 
cause the patient to inhibit the respiratory excursions of the chest. 
A similar diminution occurs with moderate pleural thickening, 
edema of the lung, the early stages of lobar pneumonia, and in 
presence of a closed pneumothorax . 

Abolition of the vesicular murmur is noted over a region of 
the thorax in which the main bronchus of a Lung is occluded, over 
a large pleural effusion, and over a pulmonary cavity which is 
filled with fluid. 

Increased Intensity of the Vesiculab Mubmub (Puerile 
Breathing). — Exaggeration of the vesicular murmur is noted over 
a lung whicb is the site of compensatory emphysema due to crip- 
pling of the opposite lung, over a circumscribed portion of a lung 
which is expanding vicariously to compensate t'<>r consolidation 
in an adjacent focus, in catarrhal inflammations of the smaller 
bronchioles, and during the dyspnea of uncompensated heart 
disease. 

Prolongation of the Expiratory Phase of the vesicular mur- 
mur accompanies hypertrophic emphysema and asthma. In these 
states the alteration in the phases of the sound is noted over 
both sides of the thorax; and in the case of asthma expiration 
is apt to be dotted with rales. Qni-lateral prolongation of the 
expiratory phase at an apex is suggestive of incipient pulmonary 
tuberculosis, particularly if noted at the left supra-clavicular 
region. 

Cog-wheel Breathing. — In certain diseases of the respiratory 
organs the respiration, particularly inspiration, occurs in a series 
of short gasps or jerks, closely simulating the sound emitted by 
a sobbing child. This jerking or cog-wheel modification of the 
vesicular murmur is a valuable sign of incipient phthisis. It 
also occurs occasionally in hysteria, asthma, chorea, local catar- 
rhal conditions of the bronchioles, in the pain of fractured rib, 
pleurodynia, or pleurisy. Although occasionally encountered in 
all of these conditions, cog-wheel breathing is a fairly reliable 
sign of pulmonary tuberculosis. 

Broncho-Vesicular Breathing. — AVhen encountered in an area 
of the chest Avhere it is not normally audible, this type of respira- 
tion points to a moderate degree of the same pathologic changes 
which produce frank bronchial breathing. Thus, it is a sign of 
partial or incomplete consolidation, as in the early stage of 



88 PHYSICAL DIAGNOSIS 

pneumonia or phthisis, or to a cavity or solid tumor which is 
overlaid by normal air-containing lung tissue. 

VOCAL RESONANCE 

Vocal resonance is the transmission of inarticulate sounds to 
the ear of the examiner during auscultation when the patient is 
directed to speak. To elicit the phenomenon of vocal resonance 
the chest-piece of the stethoscope is applied firmly and evenly 
to the surface of the thorax while the patient is directed to count 
"One, two, three," or to repeat the words "ninety-nine," with 
the face turned from the examiner. Under these circumstances 
the ear of the examiner appreciates certain rumbling, inarticu- 
late sounds, which arise in the larynx and are transmitted down- 
ward into the lung and to the surface of the chest by the air 
columns of the trachea and bronchi and the pulmonary paren- 
chyma. The intensity of the sound emanating from the chest 
varies in different regions of the thorax, being modified by the 
same factors which influence the intensity of vocal fremitus. 

Variations of Vocal Resonance 

Diminution or Absence. — The intensity of vocal resonance is 
impaired in the presence of hypertrophic emphysema or com- 
pensatory emphysema, owing to the rarefaction of the lung in- 
cident to these conditions. It is similarly diminished or abolished 
in the presence of pleural thickening, pleural effusion, and bron- 
chial obstruction. A pulmonary cavity containing fluid abolishes 
vocal resonance over the area of the cavity. 

Increased Vocal Resonance. — Vocal resonance is increased by 
the same lesions which cause increase of vocal fremitus ; namely, 
consolidations, pulmonary compression, and cavities with free 
bronchial communications. Different grades of increased vocal 
resonance are designated by different names. 

Bronchophony is a form of increased vocal resonance in which 
the transmitted voice sound is very audible, sounding as if it 
were very near the ear. However, the speech is not articulate 
as it is in the next ascending grade, pectoriloquy. Bronchophony 
points to consolidation, particularly consolidation overlying or 
superimposed upon one of the main bronchi. 

Pectoriloquy. — Pectoriloquy, the transmission of the articulate 
voice upon auscultation, is evidence of a very dense consolidation 



v 



AUSCULTATION OF RESPIRATORY ORGANS 89 

overlying a principal bronchus, or of a cavity or pneumothorax 
with free bronchial communication. More rarely pectoriloquy is 
elicited by auscultation above the level of a pleural effusion. If 
the voice is very distinct, it is very suggestive of a pulmonary cavity. 

"Whispering Pectoriloquy. — "Whispering pectoriloquy, the trans 
mission of the articulate whisper, represents the highest refinement 
of vocal resonance, and when elicited is almost conclusive evi- 
dence of the presence of a pulmonary cavity with bronchial com- 
munication or of an open pneumothorax. Normally the whispered 
voice is audible as such only over the trachea. In extensive con- 
solidations and conditions of pulmonary compression and collapse 
the whispered voice is audible but is not articulate. Practically 
the only condition in which it is articulate is a pulmonary cavity 
with free bronchial outlet. 

Baccelli's Sign. — The whispered voice is transmitted through 
a serous pleural effusion, but is not transmitted through a purulent 
effusion. This sign is utilized in differentiating between the two 
types of pleural effusion. While it is often a valuable means of 
differentiation, it not infrequently is not demonstrable ; since the 
whispered voice often fails to be transmitted through a serous ef- 
fusion of large extent. 

Modified Vocal Resonance 

Aegophony. — Iii the presence of pleurisy with effusion, upon 
auscultation immediately above the level of the fluid posteriorly 
while the patient speaks, a peculiar, quavering, nasal tone is some- 
times audible, which has been compared to the plaintive bleat of 
a goat. This peculiar sound has been designated aegophoiw. Best 
detected posteriorly near the angle of the scapula, the phenomenon 
is sometimes audible over the anterior surface of the chest above 
the level of a pleural effusion. 

Amphoric Vocal Resonance. — In the presence of large pul- 
monary cavities and pneumothorax the voice sound as appreciated 
by the usual methods frequently has engrafted upon it an echoing, 
metallic quality, analogous to the sound of the breath sounds under 
the same conditions, to which the term amphoric vocal resonance, 
or amphoric resonance has been applied. 

NEW OR ADVENTITIOUS SOUNDS 

The adventitious or new sounds which are called into being in 
diseased states of the respiratory organs comprise rales, the metal- 



90 



PHYSICAL DIAGNOSIS 



lic*tinkle, or falling -drop sound, the succussion sound or splashing, 
the pleural friction sound, and the lung-fistula sound. 

Rales. — Rales are new or adventitious sounds which arise in 
the bronchi, bronchioles, or the pulmonary alveoli, depending 
upon interference with the free ingress and egress of air during 
respiration. The lesion which is responsible for the rales may 
be a diminution of the lumen of the bronchial tube by compres- 
sion from without or swelling of the mucous membrane within, 
or spasm of the bronchial muscles ; or it may be due to an obstacle 
imposed by the presence of mucus, pus, serum, or blood within the 
bronchial tubes. 

Rales are classified as dry rales and moist rales. 

Dry rales, or rhonchi, produced by diminution of the lumen 



scncrgvs 
Kales 

Sibilant 
-RAUS 



METAIUC 
(CouGHiNC) 

on 

SvLCVSSWN 
SPLASHING 
SOUNDS 




CVRCUNC OR 
BUBBUNd T?*1-ES 
CQAnse ok 

(Also £.urqte-*) 
Fi*«. or Su bereft 
iUHT Tpa/eS 

RfPlTANf 
RALES 



Fig. 66. — Anatomic and pathologic basis of auscultatory findings. (Redrawn from Butler.) 



of the bronchial tubes, are divided into sibilant rales, when they 
reside in the smaller bronchial tubes; and sonorous rales which 
develop in the tubes of larger caliber. Sibilant rales are high in 
pitch and hissing in quality; whereas sonorous rales are of low 
pitch, and snoring, often musical quality. 

Dry rales are heard in the bronchial tubes in the earliest stages 
of bronchial inflammations prior to the pouring out of secretions 
into the lumina of the tubes, and in bronchial asthma, owing to 
constriction of the bronchioles by muscular spasm. The bruit de 
drapeau is a dry rale heard during fibrinous bronchitis, which is 
caused by the flapping back and forth of a fragment of adherent 
secretion or mucosa during inspiration and expiration. 

Moist Rales, produced by the passage of air through serum, 



AUSCULTATION OF RESPIRATORY ORGANS 91 

mucus, pus, or blood in the bronchial tubes, or to separation of 
the walls of the alveoli which have become adhered by tenaceous 
secretion, comprise the crepitant rale, the subcrepitant rale, and 
the inucous rale. 

Crepitant Rale. — The crepitant rale is produced by the separa- 
tion of the walls of the alveoli which have become adhered by tena- 
ceous secretion. Hence it is heard at the completion of full in- 
spiration. The crepitant rale is the finest of all rales and its quality 
may be simulated by rolling a small lock of hair between the thumb 
and forefinger held near the ear. Its quality lias also been com- 
pared to the series of sharp cracklings produced by throwing a 
pinch of salt upon a hot stove. The crepitant rale is not infre- 
quently confused with 'a slight pleural friction sound, which it 
closely resembles. But the crepitant rale is not accompanied by 
pain, it is more deeply seated, and it is not increased by pressure 
with the bell of the stethoscope as is the pleural friction sound. 

The crepitant rale is heard during the first stage of lobar pneu- 
monia, constituting the rale indux of this disease, it is also audible 
in catarrhal inflammation of the terminal bronchioles and alveoli 
as occurs in broncho-pneumonia or capillary bronchitis, and in pul- 
monary edema, hemorrhagic infarction, and partial atelectasis. 

Subcrepitant Rale. — The subcrepitant rale is a moist rale, a trifle 
coarser than the crepitant rale. It is produced by the passage of 
air through serum, mucus, pus or blood in the terminal bronchioles, 
causing separation of the bronchiolar walls which have been ad- 
hered. It is audible during both inspiration and expiration. The 
crepitant rale occurs during the late stages of lobar pneumonia in 
which it constitutes the rale redu.r; during acute bronchitis, hem- 
orrhagic infarction, broncho-pneumonia, and pulmonary edema. 

Mucous Rale. — Mucous rales are generated in the larger bronchi 
and in pulmonary cavities. They are audible during both inspira- 
tion and expiration ; and are best brought out by coughing or deep 
inspiration. Mucous rales are produced by the passage of air 
through a considerable accumulation of fluid. 

Gurgling Rales are generated in a cavity containing fluid with a 
free bronchial outlet which is situated below the level of the fluid 
in the cavity. Mucous rales are encountered in the course of acute 
and chronic bronchitis, bronchiectasis, and phthisis. 

The Metallic Tinkle (Falling-Drop Sound). — Occasionally dur- 
ing auscultation over a hydro- or pyo-piieumothorax, or a large 
pulmonary cavity a sound is perceived resembling the sound pro- 
duced by drops of water falling upon fluid in a container. In the 



92 



PHYSICAL DIAGNOSIS 



condition mentioned the sign may often be brought out by shak- 
ing the patient, by change of postnre, by deep inspiration or 
by coughing. Two explanations of the method of production of 
this phenomenon have been advanced; first, that it is to be at- 
tributed to the dripping of fluid from the retracted borders of 
the lung to the surface of an accumulation of fluid in the pleural 
cavity; second, that it is due to the bursting of bubbles on the 
surface of fluid in the pleural sac. 

The Succussion Sound (Splashing Sound). — A splashing sound 
which is audible upon shaking the upper portion of the patient's 
body, is termed the succussion sound, and is a reliable sign of 
the presence of air and fluid in the pleural cavity. Hence it is 



TfY 


% 


..- ,JS * 



Fig. 67. — Usual site of pleural friction sound. 



a sign of hydro-pneumothorax. The sound is not obtainable 
unless air is present with the fluid; a pleural effusion alone will 
not afford a succussion sound. Often the sound is audible at some 
distance from the patient. A succussion sound arising in the 
pleural cavity must not be confused with splashing sounds fre- 
quently arising in the stomach. 

The Pleural Friction Sound. — Owing to the small amount of 
serous fluid which normally moistens the surfaces of the visceral 
and parietal pleurae, these membranes in health glide noiselessly 
over each other during the movements of respiration. During 
inflammation of the membrane, however, and as a result of the 
excessive extraction of the body fluids which accompanies pro- 
longed diarrhea and profuse hemorrhage, there is produced a 



AUSCULTATION OF RESPIRATORY ORGANS 93 

pleural friction sound, which is audible upon auscultation of the 
surface of the thorax. 

The pleural friction sound is usually best detected in the lower 
axillary region. It is accompanied by localized pain at its site 
of production, and is localized to this region. It is a superficial 
sound, audible at the completion of inspiration, more rarely dur- 
ing expiration, disappearing on suspending respiration. It is not 
influenced by coughing, and is increased in intensity by pressure 
upon the chest wall. Its quality sometimes resembles the crush- 
ing of snow under foot, while at other times it has been com- 
pared to the sound of the creaking of new leather. It is often 
distinguished from the fine crackling of the crepitant rale with 
difficulty. When marked, the pleural friction sound is at- 
tended by friction fremitus. 

The Lung-Fistula Sound. — This term has reference to a sound 
which has been noted in cases of open hydro-pneumothorax, when 
the bronchial communication opens into the pleural cavity below 
the level of the fluid. During inspiration a series of bubbling 
gurgling sounds are generated in the pleural cavity to which the 
name lung-fistula sound has been given. 



CHAPTER VI 



THORACOMETBY AND CYSTOMETRY 

Thoracometry, or mensuration of the thorax is employed to 
determine at consecutive examinations variations in the total 
circumference of the chest; to determine the presence of uni- 
lateral bulging or retraction of the thorax; and to estimate the 
total expansion of the chest. 

In determining the total expansion of the thorax the difference 
between the circumference of the chest during complete expira- 
tion and during complete inspiration is taken, the difference be- 
tween the two measurements taken at the nipples indicating the 
total expansion of the thorax. 

In the determination of uni-lateral variations in the size of the 
two sides of the thorax it is customary to measure from the mid- 
spinal line to the mid-sternal line upon each side and note any 
discrepancies in the two measurements. AlloAvance must be 
made for the fact that the right half of the thorax is normally 
slightly larger than is the left half. In making all measurements 
of the thorax the common tape-measure is the best appliance. 

In determining the antero-posterior and transverse diameters 
of the thorax the caliper is used. In determining the antero- 
posterior diameter one point of the instrument is placed over the 
mid-sternal line and the other over the mid-spinal line and the 
measurement read off on the scale of the instrument. The 
transverse diameter of the thorax is determined by applying 
a point of the caliper to each mid-axillary line and reading the 
diameter on the scale. 

Cyrtometry, the determination of the curves of the surface of 
the thorax, is practiced by applying the cyrtometer accurately to 
the surface of the thorax. The cyrtometer consists of two pieces 
of flexible metal connected at one end by a spring. In prac- 
ticing cyrtometry of the thorax the hinge is placed over the mid- 
spinal line, and the blades of the instrument are accurately 
moulded to the surface of the thorax. Upon removal of the in- 
strument a tracing may be made showing the shape of a cross- 
section of the thorax, and revealing any uni-lateral variations in 
the two sides of the chest. 

94 



CHAPTER VII 

ROENTGENOGRAPHY AND FLUOROSCOPY 

The roentgen rays, by virtue of their power of penetrating 
anatomic and pathologic structures in direct proportion to their 
respective densities, are of very material aid in the diagnosis of 
many obscure intra-thoracic conditions; and, as they influence 
the photographic plate in the same manner as docs light, perma- 
nent records of intra-thoracic conditions may be made. The 
roentgen ray, however, is only to be considered as an aid to diag- 
nosis, serving often as a means of clearing up an otherwise obscure 
diagnosis; and its use should never supplant a careful physical 
examination of the patient. If fluoroscopy or roentgenography 
is to be used as a routine procedure, it should follow, and not 
precede, the physical examination of the patient. While many 
clinicians hold that the roentgen rays reveal tuberculous lesions 
of the lung before they can be demonstrated by the methods of 
physical examination at our command, other workers of no less 
experience hold that a skillful physical examination and a care- 
fully prepared clinical history will bring out evidences of early 
tuberculous infection before they become demonstrable by the 
roentgen ray. 

The intra-thoracic organs may be examined by the use of the 
fluoroscope, fluoroscopy ; by the taking of single photographic 
plates; skiagraphy, radiography, or roentgenography; or by the 
taking of two exposures at different focus, thus affording accurate 
depth relations, stereoroentgenography. Each method of exami- 
nation has its advantages and its special indications. While 
fluoroscopy can be utilized in studying the chest from various 
angles, it does not afford a permanent record of the case as does 
the roentgenogram. Stereoroentgenograms are of more value 
than are single plates, as they cause the different structures to 
stand out in their true relationship (Pottenger). 

The Diaphragm (Williams' Sign). — The roentgen rays afford 
the most valuable means of studying limitations and variations 
in the movements of the diaphragm. For this purpose, fluoros- 
copy is superior to other methods of examination. Upon fluoro- 

95 



96 PHYSICAL DIAGNOSIS 

scopic examination, variations in the movements, position, and 
general outline of this important muscle may be noted. Limita- 
tion of the mobility of the diaphragm on one side is often sig- 
nificant of incipient pulmonary tuberculosis (Williams' Sign). 
However, similar limitation of movement of the muscle may be 
caused by subphrenic abscess, the traction of pleural adhesions, 
or by hydatid cyst or abscess of the liver. 

While the position of the diaphragm in health is not abso- 
lutely constant, the upper border of the muscle on the right side 
usually corresponds to the upper border of the fifth rib, and on 
the left side with the upper border of the fourth rib. Fluoro- 
scopic examination may show a depression or undue elevation of 
the muscle on either side, due to supra- or infra-phrenic pressure 
or paralysis of the muscle. 

The general outline of the diaphragm is altered in diaphrag- 
matic paralysis and in the presence of diaphragmatic hernia. In 
the case of the latter affection, straining or coughing will in- 
crease the herniation of the sac contents. 

Pulmonary Tuberculosis. — In tuberculosis of the lungs the 
roentgenogram shows multiple patches of mottling in the area 
involved, a decrease in the transparency of the normal pulmonary 
tissues, not however, as dense or as sharply circumscribed as is 
the shadow cast in lobar pneumonia. On the contrary, in pul- 
monary tuberculosis there are multiple areas or impaired trans- 
parency, often superimposed, and frequently not exceeding one- 
fourth inch in diameter. In incipient tuberculosis this mottling is 
usually confined to the apical or axillary regions, the lower por- 
tions of the lungs remaining free at this stage of the morbid 
process. 

Partially healed tuberculous lesions associated with calcareous 
deposit give a greater diminution of transparency and a greater 
density, an altogether more clear-cut picture than that afforded 
by recent or active tuberculous lesions. The peri-bronchial lymph- 
glands when involved afford shadows which must be differentiated 
clinically from similar shadows due to enlargements of these 
glands which are dependent upon the acute infectious diseases 
or syphilis. Cavities, when empty, are represented by transpar- 
ent zones, usually surrounded by a darker zone corresponding to 
adjacent pulmonary consolidation. Syphilis of the lung gives 
a roentgenogram closely simulating that of pulmonary tuberculosis ; 
so much so, indeed, that the course of the disease must be studied 
in the differentiation. Abscess and gangrene of the lung yield 






ROENTGENOGRAPHY AND FLUOROSCOPY 97 




Fig. 68. — Peri-bronchial thickening in a child six and a half years of age. (From 

Pottenger.) 



98 PHYSICAL DIAGNOSIS 

signs of cavity, the differentiation from tuberculosis resting upon 
the history and clinical manifestations of the case. 

Pneumonia. — In lobar pneumonia, during the early stages 
with imperfect consolidation there is a diminution of the trans- 
parency of the normal pulmonary picture, usually having its in- 
ception around the bronchi, more rarely peripherally. When 
the consolidation is fully developed, a dark shadow with well- 
defined borders is cast, corresponding to the lobe or lobes involved 
in the disease. The shadow is occasionally so extremely dense 
as to obscure the shadows cast by the ribs overlying the area 
of consolidation. 

Broncho-pneumonia yields multiple small shadows, often super- 
imposed, and distributed over both lungs. The picture closely 
simulates that of miliary tuberculosis of the lungs. 

Chronic interstitial pneumonia, or cirrhosis of the lung, gives 
a fairly characteristic roentgenogram. Shadows corresponding 
to fibrous bands of induration extend outward in various direc- 
tions from the root of the lung toward the periphery. 

Pulmonary Neoplasms. — A large, single tumor of the lung or 
pleura is represented roentgenographically by a dense shadow 
corresponding in extent to the area of distribution of the growth. 
Small, disseminated, metastatic growths, on the contrary, give 
a picture which is with difficulty differentiated from well de- 
veloped tuberculosis of the lungs. 

Pleural Thickening. — Thickening of the pleura produces a 
fairly dense, homogeneous shadow, the density corresponding to 
the degree of thickening present. A small area of excessively 
thickened pleura closely simulates a pulmonary neoplasm. 

Pleural Effusion. — Sero-fibrinous pleurisy throws a shadow 
which is homogeneous; the opposite side of the chest should be 
studied for purposes of comparison. The disease is usually diag- 
nosed by the displacement of the diaphragm downward, and the 
cardiac displacement toward the opposite side of the chest. 

Pneumothorax. — Pneumothorax is distinguished from other 
intra-thoracic conditions by the uninterrupted transparency over 
the area involved, indicative of the absence of the lung tissue 
from this area. In pyo-pneumothorax this zone of transparency 
is bordered inferiorly by the dense shadow cast by the purulent 
collection, the upper border of which may be observed to undulate 
upon strong percussion of the chest wall during fluoroscopy. 

Mediastinal Tumors. — In the case of tumors of the mediastinum 
the shadow of the tumor is fairly accurately reproduced, and its 



ROENTGENOGRAPHY AND FLUOROSCOPY 99 

size, extent, and relation to surrounding structures may be 
studied. A single large tumor casts a relatively dense shadow, 
whereas small, metastatic growths show multiple patches of im- 
paired transparency within a fairly small space in the upper por- 
tion of the mediastinum. 

The Heart. — The roentgenogram affords a valuable means of 
investigating the size, shape, and position of the heart and peri- 
cardium. Upon fluoroscopy, which is a ready and convenient 
method of studying cardiac conditions, during forced inspiration 
the transverse diameter of the cardiac shadow appears to dimin- 
ish, to return again to its normal dimensions upon full expiration. 
Upward displacement of the diaphragm, due to increased intra- 
abdominal tension, causes an increase in the transverse shadow 
of the heart. Immense hypertrophy and dilatation also are in- 
dicated by an increase in the transverse diameter of the heart, 
whereas uni-lateral hypertrophy imparts an irregular contour to 
the cardiac shadow. Fluoroscopy and skiagraphy also reveal dis- 
placements of the heart toward the right or left by disease in the 
opposite lung or pleural sac; displacement upward by increased 
subphrenic pressure ; or displacement downward from the weight 
of an aneurism of the aortic arch, or the pressure of the lungs in 
hypertrophic emphysema. 

Pericarditis. — Acute fibrinous pericarditis yields no charac- 
teristic changes in the cardiac shadow. In sero-fibrinous peri- 
carditis, however, the shadow cast by the precordial structures 
is increased transversely, particularly toward the right, en- 
croaching upon the normal transparency in the cardio-hepatic 
angle of Ebstein. The shadow cast is not as dense as that pro- 
duced by immense cardiac hypertrophy, and in addition it is 
roughly triangular, with, the base resting upon the diaphrag- 
matic shadow, not infrequently causing downward displacement 
of the left side of this muscle. 

Aneurism of the thoracic aorta affords a shadow in the course 
of the vessel, with its size, location, and relation to surrounding 
structures. Upon fluoroscopy its pulsations ma}' occasionally be 
made out. 



SECTION III 
DISEASES OF THE BESPIKATORY OEGANS 



CHAPTER VIII 
DISEASES OF THE BRONCHI 



ACUTE BRONCHITIS 

Pathology. — Acute bronchitis, an acute catarrhal inflammation 
of the mucous membrane of the medium sized and larger bronchi, 
occurs as a primary affection, and as a complicaton of many of 
the acute infectious diseases, notably the exanthematous fevers, 
influenza, typhoid fever, and malaria. 

The disease is most prevalent during the sudden changes of 
early spring and late autumn. Among predisposing causes may 
be mentioned particularly acute coryza, affecting the upper 
respiratory passages; and passive congestion of the lungs inci- 
dent to regurgitant heart lesions, acting upon the lower portions 
of the bronchial tree. The organism which is most frequently 
causative is the pneumococcus, alone or in conjunction with the 
staphylococcus, the colon bacillus, the micrococcus catarrhal is, 
or the bacillus typhosus. 

During the early stages of the inflammation the mucosa of the 
bronchi is swollen and red, but is dry. During the further evo- 
lution of the disease, however, the congested mucous membrane 
becomes bathed with secretion, muco-purulent or purulent in 
character, containing large numbers of desquamated epithelial 
cells and bacteria. 

Physical Signs. — Mild cases of acute bronchitis yield few phys- 
ical signs, which are characteristic of the affection. In the more 
severe grades of bronchial inflammation physical signs are more 
in evidence, but often require a very careful examination to af- 
ford definite diagnostic data. 

Inspection in mild cases usually reveals nothing abnormal, but 
in more severe cases there is dyspnea; while if there is a com- 
plicating or concomitant inflammation of the finer bronchioles 

100 



DISEASES OF THE BRONCHI 101 

(capillary bronchitis), the condition is attended by a considerable 
degree of dyspnea and sometimes moderate cyanosis. 

Palpation, negative in cases of moderate severity, in well de- 
veloped cases may reveal slight rhonchal fremitus distributed over 
both lungs. 

Percussion seldom elicits any alteration of the normal vesicular 
resonance in cases of frank acute bronchitis. Occasionally in very 
severe cases a slight impairment of resonance is evident over the 
bases posteriorly. The bases should be carefully examined daily 
in order that a complicating broncho-pneumonia may be recognized 
in its inception. 

Auscultation during the early stage of the disease reveals the 
presence of sibilant and sonorous rales well distributed over both 
lungs. In a later stage of the affection, after secretion has become 
freely established, moist rales appear, the crepitant rale pre- 
dominating. 

Vocal resonance is not perceptibly altered. The respiratory mur- 
mur is harsh or puerile; but in uncomplicated acute bronchitis the 
breath sounds are never purely bronchial. 

Diagnosis. — The diagnosis of acute bronchitis rests upon the 
absence of physical signs other than puerile breathing and a 
few rales distributed over both sides of the thorax, coupled with 
certain subjective symptoms, as an initial chill followed by mod- 
erate fever, a dry hacking cough which loosens with the estab- 
lishment of the bronchial secretions; a feeling of rawness and 
pain beneath the sternum; and a general feeling of malaise and 
pains in the back and limbs. 

. In its abrupt onset the disease freciuently is suggestive of 
lobar pneumonia ; but this disease is eliminated by the absence of 
physical signs of consolidation ; namely increased vocal fremitus 
and resonance, flatness, and blowing tubular breath sounds. More- 
over, lobar pneumonia is almost always a uni-lateral affection, 
whereas acute bronchitis is bi-lateral in its manifestations. The 
constitutional toxemia and depression of lobar pneumonia far sur- 
pass that of acute bronchitis. 

Broncho-pneumonia is usually gradual and insidious in its pri- 
mary manifestations; and, in addition to the physical signs of a 
diffuse acute bronchitis, presents multiple areas of impaired res- 
onance, over which the respiratory sounds are bronchial or at the 
least are broncho-vesicular. The constitutional disturbance ac- 
companying broncho-pneumonia is more pronounced, and the 
dyspnea is of a more extreme grade. 



102 PHYSICAL DIAGNOSIS 

Pertussis, during the first week or ten days, cannot be dif- 
ferentiated from acute bronchitis ; but after the development of the 
first "whoop" the diagnosis is readily made. A history of ex- 
posure to pertussis may often be obtained. 

CHRONIC BRONCHITIS 

Pathology. — Chronic bronchitis is a chronic catarrhal inflam- 
mation of the mucous membrane of the medium sized and larger 
bronchi. Adults and elderly persons are the most frequent sub- 
jects of chronic bronchitis, the disease constituting the regular 
"winter cough" of many elderly persons. 

Occasionally developing as a result of repeated attacks of acute 
bronchitis, chronic catarrhal bronchitis is much more commonly 
a sequence of chronic cardiac and real disease, gout, or chronic 
pulmonary disease, notably emphysema, phthisis and pneumono- 
koniosis. 

In chronic bronchitis the bronchial walls are thickened from 
the deposition of fibrous connective tissue, while the bronchial 
musculature is atrophic. Frequently there is quite extensive pro- 
liferation of the mucous or goblet cells in the mucous membrane, 
which pour out a viscid grayish secretion containing innumerable 
desquamated epithelial cells. The lumen of the bronchial tube 
is in places diminished from hypertrophic thickening of the 
mucosa, while in other portions of the bronchial tree fusiform or 
saccular dilatations with atrophic mucosa and thin walls are 
present. 

The secretion of the inflamed mucosa varies in quantity and 
character, being scanty and viscid in the Catarrhe Sec of Laen- 
nec, while in the opposite condition of bronchorrhoea serosa the 
secretion is abundant and serous, rarely mucoid or muco-purulent. 
In yet another type of the disease, the so-called putrid bronchitis, 
the bronchial secretion contains small yellowish bodies of very 
foul odor, Dittrich's Plugs. .. 

Physical Signs. — Inspection. — The subject of chronic bronchitis 
is subject to attacks of shortness of breath or dyspnea upon mod- 
erate exertion. As the disease often occurs in emphysematous 
persons, the barrel chest of this disease with its limited degree of 
expansion is often seen. 

Palpation, usually negative, sometimes shows the presence of 
rhonchal fremitus over both lungs. 

Percussion. — The percussion note in chronic bronchitis is often 



DISEASES OF THE BRONCHI 103 

quite unchanged. In emphysematous subjects the note is hyper- 
resonant, while over a large bronchial dilatation which is filled the 
note is dull, changing to tympany when the contents of the dilata- 
tion are expelled. 

Auscultation. — The respiratory murmur is harsh, and in emphy- 
sematous subjects expiration is prolonged. Dry rales, sibilant and 
sonorous as well as moist rales are audible over both lungs, their 
character varying with the amount of secretion in the bronchial 
lumen. Vocal resonance is not perceptibly altered. 

Diagnosis. — A history of chronic cough recurring every winter, 
with rales generally distributed over both lungs, and frequently 
an emphysematous thorax, render diagnosis not difficult. 

The chronic cough of aortic aneurism is usually accompanied 
by stridulous respiration owing to uni-lateral vocal cord paralysis. 
The possibility of a tumor producing chronic cough by pressure 
should not be forgotten. 



BRONCHIECTASIS 

Pathology.— Dilatation of the bronchi is often the result of 
chronic bronchitis, the accumulation of the secretion in the 
weakened bronchial tubes producing dilatations. In other in- 
stances in chronic bronchitis the dilatations are produced by 
the pressure of the air in the bronchus during violent paroxysms 
of cough. Some dilatations are explained by the action of traction 
of peri-bronchial adhesions in chronic interstitial pneumonia or 
fibroid phthisis. 

The bronchial dilatations are found most commonly in the right 
lung, in which they affect mainly the bronchi of the middle and 
lower lobes. Two principal forms of dilatation are found, namely 
saccular, and cylindrical. The saccular dilatations are usually sur- 
rounded by an area of indurated lung, the dilatation having been 
produced by the traction of the adherent peri-bronchial tissues. 
Cylindrical dilatation most commonly affects the smaller bronchial 
tubes, but this form of dilatation is sometimes encountered in the 
larger tubes. The two forms of dilatation, saccular and cylindrical, 
are often found in the same lung. 

The state of the mucous membrane lining the dilatations varies. 
In some instances scarcely altered, in most cases it is thickened 
with polypoid elevations upon the surface ; or, in dilatations con- 
taining abundant secretion, the mucosa is not infrequently ulcer- 
ated. The exudation from the walls of bronchiectatic dilatations 



104 



PHYSICAL DIAGNOSIS 



is usually purulent and abundant, occasionally thick and cheesy in 
consistence. 

Physical Signs, — Inspection. — Small bronchiectatic dilatations do 
not produce characteristic physical signs. Advanced cases, in which 
the dilatations have attained considerable size, cause uni-lateral 
impairment of the expansion of the thorax, and sometimes retrac- 
tion of the affected side with drooping of the shoulder. 

Palpation. — In the presence of a large bronchiectatic cavity sit- 
uated near the surface of the lung, with a patent bronchial corn- 




Fig. 69. — Sacculated bronchiectasis. (Pottenger, . after 



Powell and Hartley.) 



munication, vocal fremitus is very markedly increased when the 
cavity is empty, to become abolished when the cavity is filled with 
fluid. 

Percussion. — The results of percussion in bronchiectasis vary, 
depending upon whether the cavity under investigation is empty or 
is filled with secretion. If the cavity or dilatation contains fluid, 
even though it has a patent bronchial outlet, the percussion note 
is flat; whereas, if the cavity is empty, it yields tympany or a 
cracked-pot sound upon percussion. In suitably situated cavities 
or dilatations all the signs of pulmonary cavity formation, such as 




Fig. 70. — Curschmann's spirals. In chronic bronchitis, the cilia within the bronchi 
whip the mucus and other inflammatory detritus into various shaped masses. Some 
are large enough to be seen with the naked eye but many require magnification to be 
seen. They commonly exist in asthmatic sputum. (From Brown.) 



n- — ;*«©£s*- 



dSPMBw SO 




Fig. 71. — Eosinophils. A considerable percentage of the pus cells of asthmatic 
sputum are eosinophils. This is probably indicative of chronic intoxication. (From 
Brown.) 



DISEASES OF THE BRONCHI 105 

Wintrich's change of sound, Friedreich's respiratory change of 

sound, and the change of sound of Gerhardt, may be elicited. 

In every case in which the signs of cavity are evanescent, present 
and absent at successive examinations, the possibility or probability 
of bronchiectasis should be borne in mind, as these cavities fill 
with secretion which masks all physical signs, and then the signs of 
cavity reappear when the contents have been evacuated. 

Auscultation. — In cases of bronchiectasis which are of relatively 
short duration, auscultation yields only the signs of chronic bron- 
chitis, puerile breath sounds and rales. If. however, a rather large 
dilatation be properly situated with reference to its bronchial out- 
let, amphoric breathing will be encountered. If a large dilatation 
is situated near the surface of the lung, and lias a free bronchial 
outlet, vocal resonance is very much exaggerated, perhaps to the 
extent of affording bronchophony or pectoriloquy. 

Diagnosis. — Cases of moderate bronchiectasis are sometimes diffi- 
cult to distinguish from chronic bronchitis, of which disease it is 
often a sequel. In cases of longer standing, in which more extensive 
organic change has occurred in the bronchial system, the expectora- 
tion of a copious amount of sputum at one time, followed by an ab- 
sence of expectoration for several hours, is suggestive: and when 
signs of cavity formation can be elicited at the base of the lung, the 
diagnosis is clear-cut and readily made. 

A bronchiectatic cavity at the base of the lung must be differ- 
entiated from a tuberculous cavity in this locality. In tuberculosis 
in addition to signs of cavity, there is apt to be considerable de- 
formity of the thorax, with fever and night sweats, while the 
course of the disease is steadily downward. In bronchiectasis, on 
the contrary, the physical signs of cavity persist for a loner perio.. 
of time, and the patient remains in comparatively good health. 



BRONCHIAL ASTHMA 

Pathology. — Bronchial or spasmodic asthma is a paroxysmal 
dyspnea which is almost entirely expiratory in type, the subject 
of the disease being unable to expel the air from the lungs. Bron- 
chial asthma has nothing in common with the so-called cardiac 
asthma or renal asthma. 

Numerous theories and hypotheses have been advanced in the 
attempt to explain the cause of bronchial asthma. Most authors 
agree that there is a marked neurotic element in these subjects. 
It has been suggested that the attack is caused by a sudden spasm 



106 



PHYSICAL DIAGNOSIS 



of the bronchial muscles; also that the obstacle to egress of the 
air from the lungs is due to narrowing of the lumen of the 
bronchioles by temporary and transient turgescence of the mu- 
cosa. Curschmann states that the underlying cause is a special 
form of inflammation of the smaller bronchial tubes, the so- 
called bronchiolitis exudativa of this author. Spasm of the dia- 
phragm has been alleged to be the underlyng cause of the 
paroxysms. 

Very little has been recorded in reference to the morbid anat- 




Fig. 72. — Charcot-Leyden crystals. These crystals are formed in sputum of chronic 
bronchitis, especially if asthma exists. They have been repeatedly found in other loca- 
tions. They seem to indicate decomposition. (From Brown.) • 



omy of this disease, as but half a dozen autopsies are contained 
in the literature. In such cases as have been examined the ciliated 
epithelium of the bronchi has been found in a state of desqua- 
mation, with bronchial congestion and exudation rich in eosino- 
philic cells. The blood during bronchial asthma contains an ex- 
cess of eosinophiles, these cells representing 25 per cent to 35 
per cent of all the leukocytes. 

The sputum in bronchial asthma is characteristic of the dis- 



DISEASES OF THE BRONCHI 107 

ease. In the early stages it is scanty and very tenacious, con- 
taining Curschmann's spirals and Chareot-Leyden's crystals. 
Macroscopically Curschmann's spirals are white or yellow, tak- 
ing the form of twisted threads or small balls. The length of the 
spiral rarely exceeds half an inch, but may exceed two inches 
in some instances. Under the microscope they appear as mucous 
threads containing a clear central fiber, around which are wound 
many fine fibrils. Eosinophiles are often entangled in the meshes 
of the fibrils. 

Charcot-Leyden crystals are colorless, pointed, octahedral <■■ 
tals, the average length of which is about three times the diameter 
of a red blood cell. The.y are often absent in freshly expectorated 
sputum, but appear after it has stood for a short time. 

During the later stages of the attack these two pathognomonic 
elements of the sputum disappear, the expectoration becoming more 
abundant and muco-purulent. 

Physical Signs. — Inspection. — The paroxysm of bronchial asthma 
comes on suddenly, dyspnea of the expiratory type being the first 
and principal sign. In the course of the paroxysm the face and 
hands become cyanotic; the veins of the neck swell ; The patient is 
obliged to sit upright in his efforts to empty the chest ; the chest is 
large and fixed; the diaphragm is depressed ; and there is a marked 
limitation of the degree of expansion of the thorax. 

Palpation. — During the attack vocal fremitis. if it can be de- 
termined, is diminished owing either to the rarefaction of the pul- 
monary parenchyma by the increased air content or to bronchial 
obstruction by swelling of the mucosa or muscular spasm. In 
certain cases rhonchal fremitus is marked. 

Percussion. — The note upon percussion is hyper-resonant, owing 
to the excess of air in the lungs which the subject is for the time 
unable to expel adequately. 

Auscultation. — The normal vesicular murmur is replaced by 
numerous loud sibilant and sonorous rales distributed over both 
lungs. These rales are so pronounced that they may often be 
heard without the use of the stethoscope. Later in the attack, 
after the bronchial secretions have become freely established, the 
dry rales give place to moist and bubbling rales. The expiratory 
phase of the vesicular murmur is markedly prolonged, being dotted 
with rales. 

Diagnosis. — Owing to the paroxysmal character of the asthmatic 
attack, its marked expiratory dyspnea, and the characteristic spu- 
tum, bronchial asthma is very readily diagnosed. 



108 PHYSICAL DIAGNOSIS 

TRACHEOBRONCHIAL STENOSIS 

Pathology. — Stenosis of the trachea or bronchi may arise from 
causes acting from the interior of the trachea or bronchi, or from 
extraneous causes. Among intra-tracheal and intra-bronchial fac- 
tors may be mentioned polypi and tumors, diphtheritic inflammation 
of the mucous lining, cicatrices from ulcers, the lodgment of foreign 
bodies, and rarely perichondritis. Among extraneous causes 
may be mentioned pressure upon the trachea by a thyroid en- 
largement, the pressure of an aneurism upon the trachea or 
bronchi, or pressure of a greatly hypertrophied heart or peri- 
cardial effusion. 

The effect of the obstruction upon the lungs depends upon the 
site of the obstruction. Total obstruction of the trachea causes 
collapse of both lungs. Obstruction of a main bronchus, causes 
collapse of one entire lung. Obstruction of a large bronchus in 
a lung causes collapse and airlessness of a large portion of the 
lung; while obstruction of a small bronchus has but little effect 
upon the lung, as only a small area of the lung is thus deprived 
of its free outlet. 

When an obstruction occurs in any portion of the bronchial 
tree, the air in the infundibula supplied by this bronchus is ab- 
sorbed and the pulmonary tissue collapses, constituting the so- 
called obturation atelectasis. 

The tissues immediately surrounding a localized bronchial ob- 
struction are emphysematous, the unobstructed portions of the 
lung expanding vicariously. 

Physical Signs.— Inspection. — The physical signs of bronchial 
and tracheal obstruction vary with the site of the obstruction. 
In tracheal obstruction the signs are bi-lateral, affecting both 
lungs, while in stenosis of one of the primary bronchi the signs 
are uni-lateral, but affect an entire lung; while in minor grades 
of obstruction, that is, in obstruction of a small bronchus or 
bronchiole, only a small portion of the lung is affected and the 
physical signs arising from the obstruction are very slight or 
nil. 

In most cases the patient is dyspneic; and, if the stenosis af- 
fects a large bronchus, there is some degree of cyanosis. In ob- 
struction of a main bronchus the expansion of the lung supplied 
is negligible, the opposite side of the chest expanding vica- 
riously. In tracheal obstruction or rather in partial tracheal ob- 
struction, there is inspiratory dsypnea, the accessory muscles 



DISEASES OF THE BRONCHI 109 

of respiration acting vigorously but only a small amount of air 
entering the lungs, so that the patient becomes rapidly cyanotic;. 
The inspiratory efforts are attended by depression of the supra- 
and infra-clavicular fossae, retraction of the intercostal spaces and 
of the epigastrium. 

Palpation. — In obstruction of a main bronchus vocal fremitus 
is abolished over the entire area of the lung. In minor grade! 
of obstruction the fremitus is little affected, owing to the small 
area of the lung involved. 

Percussion. — In obstruction of a main bronchus The percussion 
note is dull over the area of distribution of the bronchus, or over 
the entire lung. In minor degrees of obstruct ion the note is scarcely 
changed, and may be even hyper-resonant owing to the compensa- 
tory emphysema of the adjacent infundibula. 

Auscultation. — Upon auscultation over the area of an occluded 
principal bronchus the respiratory murmur is feeble or entirely 
absent, while over the opposite lung it is exaggerated or puerile. 
Coarse sonorous rales may sometimes be elicited over the site of the 
obstruction. Vocal resonance is abolished over the affected Lung 
in obstruction of a main bronchus; but is little affected in minor 
grades of obstruction. 

Diagnosis. — The presence of inspiratory dyspnea, sibilant and 
sonorous rales in a circumscribed area, and dullness over a large 
area of the lung or the entire lung is suggestive of bronchial ob- 
struction. It is important to determine the site of obstruction, 
whether in the larynx, trachea, or bronchi. In laryngeal obstruc- 
tion there is vigorous movement of the larynx, the attitude of the 
head is fixed and somewhat thrown back, and the respiration is 
stridulous. Finally, the use of the laryngoscope will reveal the 
constriction or obstructing body. Tracheal obstruction produces 
stridulous breathing, with limitation of the laryngeal movements, 
and orthopnea. 



CHAPTER IX 
CIRCULATORY DISTURBANCES OF THE LUNGS 



PULMONARY CONGESTION 

Pathology. — Congestion of the lungs occurs in two forms; 
namely as active congestion, and as passive congestion. 

Active congestion of the lungs occurs in the early stages of in- 
flammations of these organs, as in the period of engorgement of 
lobar pneumonia. But active congestion frequently occurs in con- 
ditions which do not become so grave as the first stage of pneu- 
monia, in which event it is the result usually of the inhalation of 
irritating gases, of hot or' cold air, and occurs as collateral con- 
gestion due to disease of only a portion of one lung, the congestion 
affecting an adjacent portion. Active congestion of the lungs, 
while not usually dangerous, has in rare instances ended fatally. 

Post-mortem the lung in active congestion is enlarged, is deep 
red, its consistence is increased, yet the lung will float when placed 
in water. 

Passive Congestion of the lungs occurs in two forms; namely 
as- mechanical congestion, and as hypostatic congestion. 

Mechanical congestion results from an obstacle interposed to the 
return of the blood from the lungs to the heart. The most common 
cause operating in this manner is mitral regurgitation, while a 
less frequent cause is a tumor pressing upon the great veins re- 
turning blood to the heart. Mitral stenosis and aortic insufficiency 
and stenosis operate similarly to produce mechanical congestion of 
the lungs. 

In passive congestion of the lungs the vessels of the lung are 
dilated and the inter-alveolar septa distended with fluid, while the 
air vesicles contain hemorrhagic exudate. In the alveoli are found 
desquamated alveolar cells containing blood pigment, the so- 
called "heart-failure cells." 

Hypostatic congestion of the lung is encountered in adynamic 
and asthenic states, particularly in elderly subjects who have 
been long in the recumbent posture during a continued fever or 

110 



CIRCULATORY DISTURBANCES OF LUNGS 111 

chronic wasting disease. The congestion in this instance is local- 
ized to the posterior and inferior portions of the lungs and is 
largely dependent upon general asthenia and relaxation of the 
pulmonary vessels. That it is not entirely due to the supine pos- 
ture is evidenced by the fact that it only occurs in subjects 
weakened by disease. 

Physical Signs. — Inspection. — In active congestion of the lungs 
inspection reveals the fact that the patient is dyspneic, and per- 
haps cyanotic. 

Palpation in active congestion will reveal slightly increased vocal 
fremitus, bi-lateral, most pronounced at the bases posteriorly, 
whereas in passive congestion the fremitus is less intense than 
normal. 

Percussion. — In active congestion the percussion note is apt to be 
slightly hyper-resonant owing to the increased tension of the pul- 
monary tissues; whereas in passive congestion there is impairment 
of the resonance at the bases posteriori}* owing to the gravitation 
of the blood to those regions of the pulmonary system. 

Auscultation reveals in active congestion broncho-vesicular 
breathing; and, in cases of passive congestion will show in addi- 
tion the valvular lesion which is responsible for the congestion. 
In both instances the pulmonic second sound is accentuated owing 
to the increased tension in the pulmonary circuit. In passive con- 
gestion moist or bubbling rales are not infrequently encountered 
at the bases posteriorly. 

Diagnosis. — If the physical signs detailed in the preceding 
paragraphs occur abruptly without warning, active congestion of 
the lung may be inferred ; while, if a valvular lesion of the heart 
is coupled with the respiratory siuns, the diagnosis of pulmonary 
congestion is yet more probable. 

EDEMA OF THE LUNGS 

Pathology. — Pulmonary edema arises from a number of causes, 
and may be general, involving both lungs, or local, in which 
event it is circumscribed to a portion of one lung. The most 
prolific cause of pulmonary edema is insufficiency affecting the 
mitral valve, less frequently the aortic valve, thus heightening 
the blood pressure in the pulmonary circulation. Nephritis may 
be responsible for pulmonary edema, as may local disease of the 
lung, as infarction, phthisis, or pneumonia. Angio-neurotic 
edema has been considered a cause in certain instances, while in 



112 PHYSICAL DIAGNOSIS 

other cases the edema has been attributed to vasomotor paresis. 

The edematous lung is heavy, the alveoli filled with fluid, and 
the inter-alveolar Avails are thickened and edematous. The lung 
readily pits upon pressure, and on section sero-sanguineous fluid 
exudes. 

Physical Signs. — Inspection. — The subject of pulmonary edema 
is dyspneic, the dyspnea usually amounting to orthopnea, with a 
very anxious facial expression. Cough is frequent, the cough of 
the wet lung, and the expectoration is abundant, frothy, or sero- 
sanguineous. 

Palpation reveals diminution of vocal fremitus, while rhonchal 
fremitus, the tactile equivalent of the numerous moist rales, is 
readily detected over both bases posteriorly. 

Percussion. — The resonance of the percussion note is impaired 
over the bases posteriorly, whereas over the anterior surface of the 
chest in the infra-clavicular and mammary regions skodaie reso- 
nance is not infrequently encountered. 

Auscultation. — Upon auscultation of the bases numerous mu- 
cous,, bubbling rales are heard. The pulmonic second sound is 
accentuated. 

Diagnosis.— The diagnosis rests upon the characteristic phys- 
ical signs occurring in a patient with an obstacle to the return of 
blood to the heart, or in an asthenic state, and upon the expec- 
toration of abundant frothy, sometimes blood-tinged sputum, 
which often is raised in gushes, which escape from the mouth and 
nose. 

PULMONARY INFARCTION 

Pathology. — Infarction of the lung occurs as a result of an em- 
bolus or thrombus plugging the end of one of the terminal arteries 
of the pulmonary system. The condition arises most frequently 
in connection with valvular lesions of the heart particularly those 
associated with acute or chronic endocarditis. 

The infarcts are usually situated near or at the periphery of 
the lung ; they are wedge-shaped, with the base of the wedge di- 
rected toward the surface of the lung. When recent, the areas 
of infarction are dark red in color, resembling a blood clot. 
Later, as partial organization occurs and the hemoglobin is par- 
tially removed from the mass, they assume a yellowish color. 
Eventually the infarct becomes organized, leaving a puckered 
scar at the site of the infarction. The pleura overlying an area 
of infarction usually shows signs of localized inflammation. 



CIRCULATORY DISTURBANCES OF LUNGS 113 

Microscopically the alveoli of the lung in the area of infarction 
are crowded densely with erythrocytes, which are also found in 
the inter-alveolar walls. 

Infarcts of the lung arc not infrequently multiple. In size 
they vary from that of a walnut to the size of an orange, hut in 
rare instances may be extremely large, occupyng nearly an en- 
tire lohe of a lung. 

An infarct of the lung may undergo several terminations. If, 
the embolus which plugged the terminal artery is non-infectious, 
the infarct becomes organized and eventually forms a puckered 
scar at the site of the infarction. If, on the contrary, the embolus 
be of septic origin, the infarction may be the starting point of a 
pulmonary abscess or of pulmonary gangrene. 

Physical Signs. — The signs referable to pulmonary infarction 
vary, depending upon the number, size, and distribution of the 
areas of infarction. 

Inspection reveals labored breathing, often amounting to dysp- 
nea or orthopnea. The facial expression is anxious, and hemop- 
tysis is not infrequent. 

Palpation may show increased vocal fremitus if the area of in- 
farction is of considerable extent and situated near the periphery 
of the lung, whereas, if the infarct is centrally placed, near the 
root of the lung, no alteration of vocal fremitus will be demon- 
strable. When a peripheral infarct overlies a main bronchus 
vocal fremitus is markedly exaggerated. 

Percussion. — Over large infarcts dullness is encountered, whereas 
in a large infarct directly overlying a large bronchus, the tympany 
of the bronchus is transmitted to and engrafted upon the dullness 
of the percussion note. 

Auscultation. — In suitably situated infarcts with reference to 
a main bronchus, loud, bronchial or tubular breath sounds are 
elicited, as well as rales transmitted from the bronchus. In cases 
of multiple small infarcts, or deeply seated infarction the breath 
sounds are broncho-vesicular or vesicular. 

Diagnosis. — When the signs mentioned in the preceding para- 
graphs are elicited in a patient suffering with valvular heart dis- 
ease, from which embolism might arise, infarction of the lung is 
suggested. As the infarctions are often situated in the lower lobes 
of the lung posteriorly, the physical signs arising from a large 
infarct may simulate rather closely those of lobar pneumonia. 

An infarction of moderate size which is situated centrally pro- 
duces few signs by which a diagnosis may be made, practically 



114 PHYSICAL DIAGNOSIS 

the only sign elicited being slight embarrassment of the respira- 
tion. 

A septic infarct naturally produces signs of septic poisoning 
with later development of the signs of pulmonary abscess. 

PULMONARY NEOPLASMS 

Clinical Pathology. — Tumors of the lung and pleura may be 
primary or secondary to tumor arising elsewhere in the body and 
implicating the pulmonary tissues as a result of metastasis. Of 
the two, the primary is decidedly rare, and the secondary more 
common. 

The primary tumors of the lung comprise carcinoma, sarcoma, 
and endothelioma. Carcinoma in its evolution involves usually 
one lung, where it forms a large mass, and later breaks down, 
forming a cavity. But in other cases there develops a diffuse can- 
cerous infiltration of the lung, simulating pulmonary tuberculosis. 

The secondary tumors of the lung comprise all varieties of ma- 
lignant growths. Secondary carcinoma of the lung rarely forms 
a single tumor, but is usually multiple, and not uncommonly in- 
volves the pleura. The cancerous nodules are diffusely scat- 
tered over both lungs. This represents metastases from a pri- 
mary tumor which may be situated in the breast, the gastro- 
intestinal tract, the genitourinary tract, or bone, Hodgkin's 
disease may affect the lung, traveling there by way of the me- 
diastinal and bronchial lymphatic glands. 

Carcinoma of the lung produces swelling of the bronchial 
glands and mediastinal glands and sometimes of the glands of 
the neck. Pleurisy is a common complication or accompaniment 
of pulmonary carcinoma, and may be hemorrhagic. 

Men are afflicted more frequently with primary neoplasms of 
the lungs, while women are more often the victims of secondary 
tumors in this region. 

Physical Signs. — The physical signs of. tumor of the lung may 
be caused by the presence of the tumor or may be due to the 
accompanying pleural effusion, when this is present. In the lat- 
ter event the signs of pleurisy with effusion will overshadow the 
other signs present. 

The superficial veins of the thorax and the veins of the neck 
may be tortuous and overdistended, owing to compression of 
the superior vena cava in the chest. The contour of the chest is 
changed. In the case of a very large growth there is uni-lateral 



CIRCULATORY DISTURBANCES OF LUNGS 115 

bulging and widening of the intercostal spaces, whereas in the 
case of a small growth causing collapse of the adjacent pulmonary 
tissues, or to traction by adhesions, there will be restriction of the 
expansion and local depressions of the chest wall. 

Vocal fremitus is sometimes exaggerated, at other times dimin- 
ished. A hyper-resonant note is elicited if the tumor has broken 
down and formed a superficial cavity ; while dullness or flatness is 
obtained over a large growth involving a large area of the lung. 

The breath sounds may be suppressed, may be bronchial, or am- 
phoric. The latter type of breathing is a sign of excavation of 
the lung by breaking down of the morbid growth. 

Diagnosis. — In primary cases the diagnosis is always difficult 
but the presence of strictly uni-lateral signs, with enlarged glands 
is of assistance. In pulmonary carcinoma rarely carcinomatous 
tissue may be demonstrable in the sputum ; and late in the course 
the growth may perforate the chest Avail. Mediastinal tumors 
and aneurism of the aorta are hard to differentiate. 



CHAPTER X 

DISEASES OF THE LUNGS 
LOBAR PNEUMONIA 

Pathology. — Lobar, fibrinous, or croupous pneumonia is an in- 
flammation of the lung, accompanied and attended by a variable 
degree of constitutional toxemia. 

The cause of lobar pneumonia is the pneumococcus, or diplo- 
coccus pneumoniae, first discovered in the sputum of pneumonia 
patients by Sternberg and Pasteur in 1880 and recognized as the 
cause of the disease by Fraenkel in 1884. The pneumococcus may 
be found in pure culture in the sputum of pneumonia patients or 
associated with the streptococcus, staphylococcus, or Fried- 
lander's bacillus. Present in the oral and nasal secretions of 
many persons during health, it is a question whether lobar pneu- 
monia is due to these strains of the pneumococcus or to a special 
strain. 

Lobar pneumonia is very prevalent at the extremes of life, 
young infants and elderly persons being very susceptible to the 
disease. Most cases develop during the late winter or early 
spring months. 

The morbid changes incident to lobar pneumonia pass through 
three or four rather well defined stages or periods; namely, the 
stage of engorgement, the stage of red hepatization, the stage of 
gray hepatization; and, if the patient recovers, the stage of 
resolution. However, these stages of the inflammation are not 
always recognizable as distinct and separate entities; and it is 
not uncommon to find one stage more or less blended with 
another. 

The stage of engorgement is of brief duration, rarely exceeding 
24 hours, as it is early followed by hepatization of the lung. 
During the period or stage of engorgement the lung is dark red in 
color, firm to the touch, feels boggy, but still crepitates, and the 
lung will float when placed in water. Microscopically during 
this stage the capillaries are distended with erythrocytes, the 
alveolar walls are thickened, and the alveolar spaces contain a 

116 



DISEASES OF THE LUNGS 117 

variable number of erythrocytes, leukocytes, and desquamated 
epithelial cells. 

During the stage of red hepatizaton the pulmonary tissues 
in the diseased area of the lung are solid, firm, and devoid of air. 
The lung is enlarged, and may present indentations upon its sur- 
face corresponding to the ribs with which it is in contact. Upon 
section, the cut surface is dry, reddish or brown in color, and 
very friable. Upon scraping the cut surface with the knife, 
small fibrinous plugs may come away from the terminal bron- 
chioles. The lung does not now crepitate; and sinks when placed 
in water. Microscopically the alveoli are observed to be filled 
with a dense, dry, fibrinous exudate, containing erythrocytes, 
leukocytes, and desquamated epithelial cells embedded and en- 
tangled in a matrix of fibrin, the erythrocytes predominating dur- 
ing this stage of the disease. 

In the stage of gray hepatization the pulmonary tissue loses its 
reddish color upon section and becomes more or less gray or 
grayish-white. Section shows a moister surface than in the pre- 
ceding stage, and but few fibrinous plugs can be scraped from the 
small bronchioles. Microscopically the polymorphonuclear leu- 
kocytes predominate, though some erythrocytes, as well as des- 
quamated epithelial cells, are present in the fibrinous mass. How- 
ever, in spite of this partial clearing of the alveoli, the lung is 
still not crepitant, and will sink when placed in water. 

During the stage of resolution, if it occurs, the fluid is drained 
from the lung by the lymphatics, the debris is removed by phago- 
cytes and also expectorated with the sputum, the lung gradually 
assuming its normal characters. The lung again becomes crepi- 
tant, and sections float when placed in water. 

The expectoration during the active stage of lobar pneumonia 
is thick and viscid, and of a brownish color, the so-called "prune 
juice sputum." It is so viscid that it will not always separate 
from its container when it is turned upside down. 

During the inflammation of the lung in lobar pneumonia the 
pleura is practically always involved over the area of consolida- 
tion, becoming roughened and not infrequently pouring out a 
moderate degree of serous fluid. However, in central pneumonia, 
in which the consolidation is deeply situated near the root of the 
lung the pleura escapes. It is, however, a question whether a 
pneumonia ever remains central, or whether every pneumonia 
which begins near the root of the lung eventually does not pro- 
gress and affect the periphery of the lung. 



118 PHYSICAL DIAGNOSIS 

Lobar pneumonia, as the name implies, usually involves an 
entire lobe of the lung. The disease is usually uni-lateral. In 
relative frequency the different portions of the lungs are involved 
in the following order: lower right lobe, lower left lobe, upper 
right lobe, an entire lung, or rarely both lungs. 

According to the distribution of the disease several clinical 
types of lobar pneumonia have been descrbed: 

Apical Pneumonia affects only the apex of a lung. 

Migratory Pneumonia successively involves lobe after lobe of the 
lung in regular progression. 

Double Pneumonia involves both lungs. 

Massive Pneumonia is a form in which, in addition to the alveoli, 
the bronchial tubes of an entire lobe or lung are plugged with 
fibrinous exudate. 

Central Pneumonia is a form in which the disease is situated 
deeply at the root of the lung, and does not at once involve the 
peripheral portions. 

Physical Signs. — Inspection. — The decubitus of the patient is 
often suggestive of lobar pneumonia. He may be found lying on 
the diseased side or may be found sitting up in bed with the spine 
curved toward the diseased side. Herpes labialis is a very com- 
mon finding in lobar pneumonia, and a red spot or flush upon 
the cheek of the diseased side is a very frequent sign. The 
respiratons are short and accompanied by an expiratory grunt. 

In a case of uni-lateral pneumonia, and the disease in the vast 
majority of cases is uni-lateral, inspection reveals restriction of 
the excursion of the chest on the diseased side, with exaggerated 
excursion of the sound side. The diseased side does not expand 
to its normal physiological capacity for two reasons: the air 
space in the lung is actually decreased; and, moreover, the pleu- 
risy accompanying the pneumonic process causes the patient to in- 
hibit the respiratory movements as much as possible. The sound 
lung, on the contrary, expands vicariously because it must as far 
as possible take on the work of the affected lung in order that 
the tissues may not suffer for want of their normal supply of 
oxygen. 

Litten's diaphragmatic shadow is absent on the affected side 
of the chest. 

In the cases in which the left lung is involved anteriorly, the 
cardiac impulse is very prominent, because the portion of this 
lung which overlaps the heart is enlarged and more or less firm 
and is pushed before the heart with each impact of that organ. 



DISEASES OF THE LUNGS 119 

Palpation. — Upon palpating over the consolidated or diseased 
lobe or region of the lung, particularly in the stage of red hepatiza- 
tion the most striking finding is a marked increase of vocal frem- 
itus. This increase of fremitus over the base posteriorly, where 
it is usually encountered in lobar pneumonia, is very striking since 
under normal conditions of the pulmonary parenchyma these vibra- 
tions are very indistinct or absent in this region. The fremitus is 
not altered during the period of engorgement, but appears during 
the period of red hepatization, disappearing again with the super- 
vention of resolution. 

There are two conditions under which the fremitus may be 
entirely absent over the consolidated area. If the main bronchus 
leading into this area becomes plugged with fibrinous exudate, as 
is frequently the case in massive pneumonia, the voice vibra- 
tions will not be appreciable to the palpating hand. Again, if 
there be extensive involvement of the pleura with effusion, the 
fluid masks the palpable vibrations. 

During the period of engorgement and the early part of the 
stage of red hepatization the pulse is full and bounding, the 
heart acting powerfully as a result of the raised blood pressure 
in the pulmonary circulation. In the later stages of the disease, 
when the toxemia is well established, the heart is prone to un- 
dergo more or less severe parenchymatous myocarditis, the pulse 
becoming rapid, running, and feeble. 

Percussion. — During the stage of engorgement, during the first 
twenty-four hours of the disease, the percussion note yields skodaic 
resonance. Percussion during the stage of red hepatization shows 
impaired resonance or actual flatness over the involved lobe, while 
percussion just above the consolidation, on the contrary, yields 
skodaic resonance, due to relaxation of the tissues, which are com- 
pressed by the increased size of the consolidated lobe. 

In a case of central pneumonia percussion will reveal ordinary 
vesicular resonance ; or, at most, only slight impairment of reso- 
nance, because the lung immediately beneath the chest wall is not 
consolidated, and yet such a patient will exhibit all the toxic symp- 
toms of a severe lobar pneumonia. 

During the latter portion of the stage of gray hepatization and 
during the stage of resolution, the lung shows a gradual return to 
the normal vesicular resonance over the diseased area. 

Auscultation. — During the period of engorgement the breath 
sounds are quiet and partially suppressed, while at the comple- 
tion of full inspiration there occurs a very valuable diagnostic 



120 PHYSICAL DIAGNOSIS 

sign, namely a fine crepitant rale, the rale indux. This rale is 
produced by the separation of the walls of the infundibnla which 
have been glued together with sticky, viscid exudate, and pre- 
sents to the examining ear a series of sharp cracklings. 

When the consolidation is well established, in the stage of red 
hepatization, this rale disappears, and is replaced by distinct 
bronchial or tubular breathing. During the latter portion of the 
stage of gray hepatization and during the period of resolution, 
when the consolidation becomes macerated and partially dissolved 
by serum, the bronchial breath sounds disappear and are re- 
placed by a sub-crepitant rale, the rale redux, which is produced 
by the separation and approximation of the finer bronchiolar 
walls during expiration and inspiration. 

The pulmonic second sound is accentuated owing to the in- 
creased load thrown upon the right heart due to the obstacle 
offered to the passage of the blood through the diseased lung. In 
prolonged and severe cases there is frequently a reduplication of 
the second sound of the heart, due to a-synchronous closure of 
the aortic and pulmonic valves, caused by the unequal tension in 
the general and pulmonary circulations. 

Diagnosis. — In a case of frank lobar pneumonia in an adult 
with sudden onset with pain in the side, initial chill and rapidly 
rising fever, coupled with the development of a rusty tenaceous 
sputum, the diagnosis is not difficult. But in young children, in 
the aged, in alcoholic subjects, and in terminal or secondary pneu- 
monias engrafted upon other conditions as cancer, nephritis or 
diabetes, the diagnosis is often reached with difficulty. 

In a case of frank uncomplicated lobar pneumonia the physical 
signs are distinctive ; lessened or deficient expansion of the dis- 
eased side of the thorax, exaggeration of vocal fremitus, dull- 
ness or flatness on percussion, bronchial breathing with the sub- 
crepitant and crepitant rale on auscultation. But it should be 
remembered that in massive pneumonia the vocal fremitus may be 
lessened or absent over the diseased area owing to the main 
bronchus supplying the part being plugged with tenacdous exu- 
date. Moreover, in ordinary pneumonia, in the routine case so 
to speak, the dullness is preceded and followed by a rather tym- 
panitic note, occurring prior to and following complete and frank 
hepatization of the pulmonary tissue in the area of disease. So 
also the bronchial breath sounds are absent or a-typical in the 
presence of incomplete hepatization of the lung, in partial plug- 
ging of a bronchus, or in the presence of a complicating pleurisy 



DISEASES OF THE LUNGS 121 

with effusion. Other data for diagnosis are that the disease 
usually terminates by crisis at the 7th or 9th day; that the onset 
is abrupt; that the pulse-respiration ratio is markedly altered; 
that there is usually labial herpes; and that there is usually a 
hectic flush upon the cheek upon the side of the disease. 

The localization of the disease in the lung is prone to influence 
the physical signs and give trouble in diagnosis. Thus, in Mas- 
sive Pneumonia the ordinary physical signs may be Lacking over 
a large area of the lung, giving physical signs simulating pleurisy 
with effusion. In this class of cases it is occasionally possible to 
dislodge the plugging exudate by coughing. 

Central pneumonia does not give the typical picture of frank 
lobar pneumonia. Here the lesion, starting deeply within the 
lung, overlaid as it is by normal pulmonary tissues, yields a 
rather broncho-vesicular respiratory murmur and only moderate 
impairment of pulmonary resonance. However, as a rule, these 
cases can only be said to be central in their incipiency, as they 
usually eventuate in an ordinary lobar pneumonia involving the 
peripheral portions of the lung. 

Lobar pneumonia not infrequently is a source of pain in the 
right lower portion of the abdomen, thus simulating acute appen- 
dicitis. In other instances the disease is attended by constipation, 
abdominal pain and meteorism, simulating intestinal obstruction. 

In drunkards the cerebral symptoms of pneumonia predomi- 
nate; while in children cerebral symptoms arc prominent and the 
rusty sputum may be absent throughout the course of the disease. 

Lobar pneumonia must be differentiated from Acute Tuber- 
culo-pneumonic phthisis, broncho-pneumonia, pulmonary infarc- 
tion, pulmonary edema, pulmonary congestion from cardiac de- 
fects, and from pleurisy with effusion. 

Acute Tuberculo-Pneumonic Phthisis. — In the early stages of 
the disease it is often impossible to differentiate between this 
disease and lobar pneumonia. This form of tuberculosis, often 
termed " galloping consumption," begins abruptly with chill, 
pain in the side, and cough attended by sputum which is at first 
mucoid, and later rusty. The physical signs are those of consoli- 
dation of one or more lobes, or possibly of an entire lung. The 
chill is followed by a rapid rise of fever and the picture is that 
of frank lobar pneumonia. But at the seventh or ninth day no 
crisis occurs ; but, on the contrary, the fever persists, is attended 
by night sweats, Avhile elastic fibers and tubercle bacilli appear in 



122 PHYSICAL DIAGNOSIS 

the sputum. Evidence of softening now appears, with moist or 
gurgling rales and other signs of cavity formation. 

Broncho-Pneumonia. — Broncho-pneumonia is usually gradual 
in onset and is usually secondary to other infectious fevers, as 
measles, influenza, scarlatina, or typhoid fever, or occurs as the 
result of the aspiration of blood from hemoptysis or the decompo- 
sition of the contents of bronchiectatic cavities. 

The distribution of the disease is of aid in differentiating the 
two conditions, broncho-pneumonia being bi-lateral, whereas 
lobar pneumonia as a rule affects one lobe or one lung. More- 
over, the age at which the two diseases are most prevalent dif- 
fer. Broncho-pneumonia is most frequently encountered in young 
children, under three years of age, whereas lobar pneumonia is 
much more common after the third year. 

The physical signs of broncho-pneumonia are diffuse, the 
patches of consolidation being scattered well over both lungs, so 
that the percussion note is never frankly dull or flat, but there is 
bi-lateral moderate impairment of pulmonary resonance. Simi- 
larly broncho-pneumonia is not attended by frank bronchial 
breathing, but rather by broncho-vesicular breathing. 

Finally, broncho-pneumonia resolves by lysis, whereas lobar 
pneumonia terminates by crisis. 

Pulmonary Infarction. — Infarction is abrupt in onset with 
dyspnea, cough, and the expectoration is not viscid, but fluid and 
often tinged with blood or almost pure blood. In simple infarc- 
tion there is less fever than in lobar pneumonia; but in septic in- 
farction a local pneumonia frequently develops at the site of the 
infarct, and leads to pulmonary abscess with its hectic tempera- 
ture and sweats. There are often signs of an associated heart 
lesion. Infarction most frequently occurs in persons who suffer 
with chronic endocarditis. 

Unless very large the infarcts produce very few distinctive 
signs, though large ones in the lower lobes produce broncho- 
vesicular or bronchial respiration when properly situated with 
reference to a large bronchus. 

Pulmonary Edema develops in patients with valvular heart 
lesions, or nephritis, producing extreme dyspnea or orthopnea, 
with numerous liquid rales at the bases posteriorly. The respira- 
tory sounds are weakened rather than purely bronchial. The 
sputum is abundant and characteristic ; the condition is bi-lateral, 
affecting the bases of both lungs; and it is not accompanied by 
fever. 



DISEASES OF THE LUNGS 123 

Pulmonary Congestion. — The variety of pulmonary congestion 
most closely simulating lobar pneumonia is the acute active con- 
gestion described as Woillez's disease, a form of active conges- 
tion of sudden onset, which really constitutes a larval type of 
pneumonia. Hypostatic congestion is bi-lateral in its manifesta- 
tions, with moist rales at the bases of the lungs; but no fever, 
or sputum. 

Pleurisy With Effusion may closely simulate lobar pneumonia, 
but there are sufficient diagnostic data to differentiate the two 
diseases. 

In pleurisy with effusion the onset is gradual with chilly sen- 
sations rather abrupt Avith a distinct chill as in lobar pneumonia. 
Pleurisy in the early stage is almost always accompanied by a 
pleural friction sound, which disappears as the effusion accumu- 
lates in the pleural cavity. Pleuritic fever resolves by lysis, while 
the fever of pneumonia terminates by crisis. There is often a tu- 
berculous history obtainable in connection with pleurisy. In 
pleurisy with effusion the vocal fremitus is abolished, instead of 
exaggerated as in pneumonia. There is flatness on percussion, 
whereas in pneumonia the note is dull, being preceded and fol- 
lowed by a rather tympanitic note during the stages of incom- 
plete hepatization. Instead of the crepitant and sub-erepitant 
rales of pneumonia, in pleurisy with effusion there is a total ab- 
sence of the respiratory sounds, or at the least a very great de- 
crease in their intensity. Aspiration of the thorax reveals fluid 
in the case of pleurisy with effusion. 

Herpes of the lips is rare in pleurisy, common in pneumonia. 
Egophony may be elicited below the clavicle and scapular angle 
in pleurisy with effusion, and the cardiac apex beat is displaced 
to the side opposite to the effusion. The intercostal spaces are 
more apt to be obliterated or to bulge in pleurisy with effusion 
than with pneumonia. Finally, visceral displacement is more pro- 
nounced in pleurisy than in pneumonia. 

BRONCHO-PNEUMONIA 

Pathology. — Broncho-pneumonia, catarrhal, or lobular pneu- 
monia, is an acute inflammation of the terminal bronchioles, 
spreading secondarily to the adjacent alveoli, which become 
filled with inflammatory exudate from the terminal bronchioles. 

Broncho-pneumonia is nearly always a secondary disease, fol- 
lowing many of the infectious fevers, as pertussis, measles, influ- 



124 



PHYSICAL DIAGNOSIS 



enza, diphtheria, scarlatina, smallpox, or typhoid fever, diseases 
which during their course have been associated with a greater or 
less degree of bronchitis. In these instances the development of 
a broncho-pneumonia merely represents a downward extension 
of the acute bronchitis to the finer bronchioles. Broncho-pneu- 
monia also follows the aspiration into the bronchi of particles 
of food, or secretions or blood from the upper respiratory pas- 
sages, (aspiration or deglutition pneumonia). In apoplexy and 
other comatose states these particles are prone to be aspirated 
into the bronchi and set up a broncho-pneumonia. Aspiration 
pneumonia occurring in the newly born is due to the aspiration 
of secretions from the birth canal during labor. 



38K 




Fig. 73. — Consolidation of broncho-pneumonia. (From Delafield and Prudden.) 



Broncho-pneumonia is very common in infancy, attacking many 
children under one year of age. In this class of patients the pres- 
ence of rickets or severe diarrhea predisposes to the development 
of the disease. 

A primary broncho-pneumonia occasionally develops in adults 
and children who are below par, in which the onset of the disease 
is abrupt, simulating lobar pneumonia. 

The organisms most frequently responsible for broncho-pneu- 
monia are Friedlander's bacillus, and the pneumococcus of Fraen- 
kel. These organisms may occur alone or in association with the 
streptococcus, influenza bacillus, colon bacillus, or staphy- 
lococcus. 



DISEASES OF THE LUNGS 125 

In broncho-pneumonia the lung presents upon its surface scat- 
tered patches of consolidation, separated by areas of compensa- 
tory emphysema. The consolidated patches are red or grayish, 
and slightly elevated above the surrounding surface of the lung. 
The disease is bi-lateral, affecting both lungs, which remain 
crepitant despite the multiple areas of consolidation, and the 
lung will float when placed in water. 

When the lung is sectioned the pneumonic patches of consoli- 
dation are observed to be situated in and confined to the periph- 
eral portions of the lung, just subjacent to the pleura. 

The terminal bronchioles are filled with muco-purulent exu- 
date; while the peri-bronchial tissues are consolidated in the 
immediate vicinity of the bronchus, and splenized for some dis- 
tance beyond the area of consolidation. Microscopically the 
bronchial Avails present swelling and desquamation of the lining 
cells, while the bronchial lumen is filled with muco-purulent exu- 
date, composed mainly of desquamated bronehiolar cells and 
with very few erythrocytes or leukocytes. The bronchial walls 
and inter-alveolar septa in the consolidated areas show infiltra- 
tion with leukocytes. 

The distribution of the disease varies. As the name implies, 
the disease has a tendency to involve lobules rather than lobes of 
the lung. As a rule, this principle holds good in the distribution 
of the lesions, which usually assume one of two types. Thus in 
the disseminated form of broncho-pneumonia lobules are consoli- 
dated all over the two lungs, the areas of consolidation being sep- 
arated by areas of crepitant lung. In the pseudo-lobar form, 
however, a number of lobules in one lobe are consolidated, per- 
haps the greater portion of a lobe of the lung. 

Broncho-pneumonia may terminate in resolution, in abscess, in 
fibrosis, or in gangrene. In the cases which terminate by resolu- 
tion the cellular exudate in the bronchioles and alveoli becomes 
liquefied, largely as a result of fatty degeneration, and is borne 
away by the lymphatics or is expectorated. 

The pleura is frequently involved in broncho-pneumonia, but 
not to the same extent as in lobar pneumonia ; but when pleurisy 
develops with broncho-pneumonia it is very apt to be purulent. 

The expectoration in broncho-pneumonia is tenacious and 
glairy, containing no characteristic elements. 

Physical Signs. — Inspection. — Broncho-pneumonia is attended 
by dyspnea, the accessory muscles of respiration coming into 
play with retraction of the lower interspaces and epigastrium 



126 PHYSICAL DIAGNOSIS 

during inspiration. In children there are not infrequently cya- 
nosis and suffocative attacks. There is cough, which with the 
dyspnea and cyanosis developing in a child convalescing from an 
acute infectious disease should direct the examiner's attention to 
the lungs. In many instances in children the disease is ushered 
in with convulsions. 

Palpation may reveal increase in the vocal fremitus if there is a 
patch of consolidation of sufficient size and favorably located 
with reference to a bronchus. However, the intervening emphy- 
sematous portions of the lung tend to mask the fremitus, which 
may be actually diminished. Similarly, occlusion of a bronchus 
by secretion may abolish the fremitus. In the pseudo-lobar form 
of the disease there is always increase of vocal fremitus, whereas 
in the disseminated form such an increase is not to be expected. 

Permission may reveal multiple patches of impaired resonance or 
dullness, particularly over the bases posteriorly. However, the 
thorax of the young child, in whom the disease is very frequently 
encountered, is naturally rather resonant; and the areas of com- 
pensatory emphysema surrounding and separating the areas of 
consolidation tend to mask the dullness which would be evi- 
denced by these areas and to impart a vesiculo-tympanitic quality 
to the percussion note. In the disseminated form of broncho- 
pneumonia dullness is not to be expected, as the areas of emphy- 
sema mask the dullness which might be caused by the areas of 
consolidation. In the pseudo-lobar form, on the contrary, there 
is frequently dullness at the bases posteriorly, which may be 
elicited by careful daily percussion of these areas. In demon- 
strating the areas of dullness it is necessary to employ very light 
percussion. 

Percussion of the anterior regions of the thorax in these cases 
will yield hyper-resonance due to compensatory emphysema of 
these portions of the lungs. 

Given any case of broncho-pneumonia, during the first twenty- 
four hours of the disease percussion will reveal no alteration in 
the percussion note; but the bases posteriorly should be per- 
cussed daily in a suspected case; and in most instances by the 
end of forty-eight hours dullness will have developed in these 
regions. 

Auscultation. — Auscultation reveals upon consecutive examina- 
tions the downward extension of the original bronchitis. In ad- 
dition to the rales arising in the bronchial tubes incident to the 
bronchitis, the crepitant rale is heard upon the completion of in- 



DISEASES OF THE LUNGS 127 

spiration over the bases posteriorly, indicating the participation 
of the alveoli in the inflammatory process. At times the rales may 
be masked by plugging of the bronchi by exudate; but coughing 
usually serves to bring them again to the fore. 

As the patches of consolidation form the respiratory sounds 
assume a broncho-vesicular character, but never become purely 
bronchial. 

The pulmonic second sound is accentuated during the height 
of the disease; and if the right heart fails, edema of the lung 
supervenes, with the characteristic signs of that condition. 

In the presence of considerable consolidation of the bases, 
bronchophony may sometimes be elicited just above the level of 
the consolidation. Over the anterior surface of the thorax, in 
the region of compensatory emphysema, the expiratory murmur 
is slightly prolonged, and accompanied by sibilant piping rales. 

Diagnosis. — The physical signs of broncho-pneumonia, while 
bi-lateral, are seldom present to the same degree upon both sides 
of the thorax, one lung usually being involved to a greater ex- 
tent than is the other. Whenever physical signs of consolidation 
are elicited over one lung, a careful search for similar signs 
should be made over the opposite lung. 

Very often a diagnosis of broncho-pneumonia cannot be made 
upon the physical signs alone, as these are often misleading, and 
as the mode of onset of the disease is not infrequently atypical. 
The physical findings should be considered in conjunction with 
the fever, cough, dyspnea, and pain arising during the course of 
an acute infectious disease, or engrafted upon a previous acute 
bronchitis. 

Occurring as the disease does during the course of or conva- 
lescence from some other disease, the picture is often modified 
for a time at least by the characters of the primary affection. 
But a history of fever, dyspnea, cough, and pain in the chest, 
arising during the course of an acute infection or engrafted upon 
a previous bronchitis is suggestive of broncho-pneumonia. 

From acute bronchitis the disease is differentiated by the ab- 
sence of areas of hyper-resonance and impaired resonance in the 
former, and by the finer quality of the rales in broncho-pneumonia. 
Moreover, with acute bronchitis there is less fever, and the dis- 
ease is altogether milder in its manifestations. 

From labor pneumonia, broncho-pneumonia presents many points 
of differentiation. Broncho-pneumonia is usually secondary to an- 
other disease, and of insidious onset; whereas lobar pneumonia is 



128 PHYSICAL DIAGNOSIS 

usually a primary disease, with abrupt and stormy onset. More- 
over, broncho-pneumonia is a bi-lateral pulmonary disease, pro- 
ducing many areas of impaired resonance over both lungs, rather 
than a single area of flatness over one lobe of the lung. Also, 
broncho-pneumonia terminates, or resolves by lysis, whereas lobar 
pneumonia terminates by crisis usually between the 7th and 9th 
days. As a rule broncho-pneumonia attacks subjects of im- 
paired vigor who are below par, whereas lobar pneumonia usually 
affects robust persons, in the prime of health. 

In the primary form of broncho-pneumonia, particularly if the 
disease assumes the pseudo-lobar form, in which the . pneumonic 
patches fuse and involve the greater portion of a lobe, the dif- 
ferentiation from lobar pneumonia is attended with considerable 
difficulty. In this class of cases the physical signs are very simi- 
lar if not identical ; but in broncho-pneumonia there is nearly al- 
ways apparent, if even to a slight degree, some involvement of the 
opposite lung. 

In lobar pneumonia the fever is higher and the prostration more 
profound than in broncho-pneumonia; and the sputum is viscid 
and rusty, whereas in broncho-pneumonia it is tenaceous and 
glairy, often muco-purulent. 

From the broncho-pneumonic form of acute tuberculo-pneu- 
monic phthisis, broncho-pneumonia cannot be differentiated in 
the early stages. Involvement of the apices by the disease is sug- 
gestive of phthisis ; but in certain cases of tuberculo-pneumonic 
phthisis the apical involvement is not particularly prominent. 
However, in phthisis the temperature is prone to remain more 
uniformly high, and to be interrupted by night sweats. There is 
usually obtainable a history of intimate association with a tuber- 
culous person or evidence of a tuberculous focus at some point. 
Moreover, in the broncho-pneumonic form of acute tuberculo- 
pneumonic phthisis emaciation progresses rapidly, the course 
of the disease being progressively downward, until eventually 
tubercle bacilli can be demonstrated in the sputum. 

Broncho-pneumonia in infancy is sometimes with difficulty dif- 
ferentiated from meningitis, as the disease in this class of pa- 
tients is often accompanied by marked cerebral symptoms, as de- 
lirium or convulsions. Time and observation are essential to a 
differential diagnosis under these circumstances. 



DISEASES OF THE LUNGS 129 

CHRONIC INTERSTITIAL PNEUMONIA 

Pathology. — Chronic Interstitial Pneumonia, productive pneu- 
monia, cirrhosis or fibrosis of the lung, is a chronic condition, the 
result of prolonged and continued irritation involving either 
smaller or larger areas of the lung. The predominant pathologic 
feature of the disease is the formation of an excess of fibrous con- 
nective tissue, which by contraction decreases the size and air 
space of the lung. 

Chronic interstitial pneumonia may be a sequence of either 






$&*" Ni m %. /£& 



i / 




&s?\ 



c. 



\ A $ 









Fig. 74. — Interstitial pneumonia with emphysema. (From Delaheld and Prudden.) 

lobar or broncho-pneumonia, when instead of resolution occur- 
ring the disease terminates, in fibrosis or gray induration of the 
lung. In other instances the cirrhotic process has its point of 
inception in the pleura, the result of chronic pleurisy, in which 
event the connective tissue formation develops along the inter- 
alveolar septa. Localized areas of fibrosis of the lung accom- 
pany pulmonary tuberculosis, result from the continued inhala- 
tion of irritating dusts or vapors, and develop as a result of pul- 
monary syphilis. 

Two forms of chronic interstitial pneumonia have been de- 



130 PHYSICAL DIAGNOSIS 

scribed; namely, a massive or lobar form, and an insular or 
broncho-pneumonic form. 

In the massive form of the disease one lung is involved. This 
lung is shrunken, the alveolar walls being much thickened and 
the alveolar spaces much smaller than is normal; the lung is 
drawn up into the pleural cavity, occupying a very small area 
near the spinal column. In cases resulting from pneumonia the 
pleura shows little change; but in cases of pleurogenous origin 
this membrane shows great thickening. The bronchial tubes 
show numerous dilatations, surrounded by masses of indurated 
lung tissue, the dilatations having resulted from the traction of 
peri-bronchial adhesions. 

In the insular or broncho-pneumonic form of the disease the 
areas of fibrosis are small and are generally distributed through- 
out the base and lower lobe of the lung. 

In both forms of the disease the opposite lung is found in a 
state of compensatory emphysema. 

Physical Signs. — Inspection. — The affected side of the chest is 
deficient in expansion, immobile or moving but little with the 
respirations, retracted, with drawing downward of the shoulder. 
The cardiac impulse is displaced toward the affected side, and 
there is not uncommonly a very wide area of impulse in the 3rd 
and 4th interspaces. Owing to the retraction of the diseased 
side the nipple and scapula approach more nearly to the median 
line than is normal. There is spinal curvature, with the con- 
cavity toward the side of the disease. 

The disease is uni-lateral; hence, if the left lung be involved the 
cardiac impulse is displaced toward the left, giving a wide area 
of visible impulse. If, however, the right lung is the seat of the 
disease, the cardiac impulse is often not visible, as it is not in- 
frequently displaced to the right so that it lies behind the ster- 
num. If the cardiac displacement accompanying right sided cir- 
rhosis is not so extreme as to displace the impulse behind the 
sternum, it may still be invisible owing to overlapping of the 
apex of the heart by the compensatorily emphysematous left lung. 

Palpation. — In the majority of cases of chronic interstitial pneu- 
monia vocal fremitus is increased, although in cases of pleurogenous 
origin, associated with considerable pleural thickening, it may be 
diminished. In these cases a pleural friction fremitus can some- 
times be appreciated. Over a bronchial dilatation which approaches 
the wall of the axillary region vocal fremitus is markedly increased. 
Percussion. — Percussion over the retracted lung yields a dull or 



DISEASES OF THE LU1 131 

flal note; while percussion over the opposite lung reveals hyper- 
resonance due to compensatory emphysema. Percussion over the 
axillary region not infrequently yields a tympanitic onto, due to 
the close proximity of a bronchial dilatation. The upper limit of 
pulmonary resonance is diminished on the side of the disease owing 
to shrinking of the pulmonary apex. Similarly in involvement of 
the right lung the lower border of pulmonary resonance is elevated, 
the liver pushing the diaphragm upward ; whereas in left sided dis- 
ease the tympany of Traube's semilunar space extends higher than 
normally. 

Auscultation of the affected side reveals bronchial breathing over 
the retracted and shrunken lung, which, over dilated bronchi or 
bronchiectatic cavities frequently has an amphoric or cavernous 
quality engrafted upon it. Over the lower portion of the thorax 
of the affected side the breath sounds are feeble or entirely 
abolished. The same is true of cases of pleurogenous origin with 
thickening of the pleura. 

Over the pulmonary apex and in the axillary region the respi- 
ratory murmur is usually broncho-vesicular, not infrequently 
amphoric. Over the opposite half of the thorax the respiratory 
murmur is harsh or puerile from compensatory emphysema. In 
pleurogenous cases a friction rub can often be heard over the 
cirrhosed lung. 

The pulmonic second sound is accentuated: and late in the 
course of the disease, is apt to become weakened, the tricuspid 
systolic ''safety-valve" murmur then becoming audible, betok- 
ening imminent right heart failure. 

Diagnosis. — AVhen a patient presents the physical signs detailed 
in the preceding paragraphs, with a history of chronic cough 
and shortness of breath, with good nutrition and fairly good 
health, despite the fact that he has been affected thus for a con- 
siderable length of time, sometimes for several years, chronic 
interstitial pneumonia is suggested. If, in addition, a history is 
obtained of these signs and symptoms supervening upon a pre- 
vious lobar or catarrhal pneumonia or pleurisy, the diagnosis is 
still more probable. Slowly growing tumors of the lung or pleura 
may rather closely simulate the physical signs of chronic inter- 
stitial pneumonia. 

It is to be borne in mind that the physical signs of fibroid 
phthisis are largely identical with those of chronic interstitial 
pneumonia. In tuberculosis, however, both lungs are apt to be 
involved in the fibrosis, and the sputum contains tubercle bacilli. 



132 PHYSICAL DIAGNOSIS 

ACUTE TUBERCULO-PNEUMONIC PHTHISIS 

Pathology. — Acute tuberculo-pneumonic phthisis occurs in two 
forms: The pneumonic form, and the broncho-pneumonic form 
of the disease. 

In the pneumonic form of acute tuberculo-pneumonic phthisis 
only one lobe or the entire lung may be involved. The disease 
commonly starts from a tuberculous focus in one apex. The lung 
in this form of the disease is heavy, the affected portion devoid 
of air, and the pleura covered with a thin exudate. Upon sec- 
tion the picture closely resembles that of lobar pneumonia during 
the stage of hepatization. Males are attacked with this form of 
the disease more frequently than females. 

The broncho-pneumonic form of acute tuberculo-pneumonic 
phthisis most frequently attacks children. Pathologically it is a 
caseous broncho-pneumonia which starts in the small bronchioles, 
which become blocked with cheesy material, while the alveoli 
are filled with the products of a catarrhal pneumonia. 

By the fusion of several areas of the disease process almost an 
entire lobe may become involved ; but in most instances the areas 
of disease are separated by air-containing lung. 

Physical Signs of the Pneumonic Form. — Inspection. — The dis- 
ease is characterized frequently by acute suffocative attacks of dysp- 
nea with cyanosis. The sputum is mucoid and may or may not 
contain tubercle bacilli. 

Palpation reveals increase of vocal fremitus over the consoli- 
dated area, which is usually chiefly confined to the upper lobe of 
the lung. Palpation may also detect lagging inspiratory inflation 
of the apices. 

Percussion shows dullness over the area of consolidation; but 
very early in the disease the percussion note is often hyper-res- 
onant. 

Auscultation. — The first or earliest auscultatory findings are a 
suppression of the respiratory sounds, which later become broncho- 
vesicular or purely bronchial. This purely tubular breathing con- 
tinues for a week or ten days, when, instead of clearing and dis- 
appearing as in lobar pneumonia, signs of cavity formation, indi- 
cating softening appear. 

Physical Signs of the Broncho-Pneumonic Form. — Inspection 
shows that the child is dyspneic, with cough, emaciation, and hectic 
flush. 



DISEASES OF THE LUNGS 133 

Palpation reveals multiple patches of increased vocal fremitus, 
most marked about the apices of the lungs. 

Percussion. — The percussion note is seldom dull. It is rather 
vesiculotympanitic produced by the multiple small patches of con- 
solidation with intervening emphysematous tissues. 

Auscultation. — The respiratory murmur over the areas of con- 
solidation is of the broncho-vesicular type, not attaining the purely 
bronchial character. There arc crepitanl and sub-crepitant rales. 
The auscultatory signs are largely those of a very acute bronchitis. 

Diagnosis. — The pneumonic form of acute tuberculo-pneumonic 
phthisis must be differentiated from lobar pneumonia of the 
croupous type. In the early stages this is difficult; 1 nit it is to be 
remembered that this form of phthisis is prone t<> appear first in 
the apices, while lobar pneumonia is prone to involve the ba- 
the lung posteriorly. Moreover, at the seventh or ninth day, 
instead of a crisis occurring with amelioration of the most acute 
symptoms, the disease in the case of phthisis runs on and becomes 
aggravated, sweats occurring, and the sputum developing the 
tubercle bacillus and elastic fibers. 

The broncho-pneumonic form of acute tuberculo-pneumonic 
phthisis must be differentiated from non-tuberculous broncho- 
pneumonia, a problem which requires time and observation. A 
broncho-pneumonia Inning its inception in the apices of the lungs 
is suggestive of tuberculosis. Also the rapid emaciation of the 
subject points to the same disease: while the finding of the tu- 
bercle bacillus renders the differentiation positive. 

CHRONIC ULCERATIVE PHTHISIS 

Pathology. — Chronic ulcerative phthisis has its inception in a 
tuberculous focus in one or both apices and extends progressively 
downward in the lung. From an apical lesion infective material 
is aspirated into the bronchi of uninfected portions of the lungs 
and here sets up tubercle formation about the finer bronchioles. 
Thence the disease spreads to the infundibula, and, less commonly, 
ascending infection occurs, leading to infection of the bronchi 
above the smaller bronchioles. 

Extension of infection also travels by continuity of tissue from 
a primary focus to the immediately surrounding portions of the 
lung. Infection frequently travels by the lymphatics or blood 
stream, infecting other portions of the pulmonary tissues. 
Through these avenues and these means the infection of the lung 



134 



PHYSICAL DIAGNOSIS 



when once started travels progressively downward, involving 
lobule after lobule and lobe after lobe of the lnng. 

In the further progress of the disease different portions of the 
lung show tubercles in different stages of infiltration, sclerosis, 




Fig. 75. — Illustrating caseous tuberculosis. Large cavities at the apex and many small 
cavities throughout the lung. (Pottenger, after Tendeloo.) 



or caseation and softening, leading eventually to cavity forma- 
tion. 

Ulceration of the walls of the bronchial tubes not infrequently 
permits stretching of these Avails during paroxysms of cough or 



DISEASES OF THE LUNGS 



135 



from the weight of stagnating secretions, with the formation of 
dilatations or bronchiectatic cavities. 




Fig. 76. — Illustrating pulmonary tuberculosis, with thickened pleura, many bronchiectatic 
cavities, and generalized cavity formation. (Pottenger, after Tendeloo.) 



Aside from the bronchiectatic eavites, cavities may be formed 
in the pulmonary tissues apart from the bronchi. The walls on 
these cavities in some instances are smooth, while in other cases they 
are uneven and ragged. In these cavities blood vessels which 



136 PHYSICAL DIAGNOSIS 

have not been destroyed may be found traversing the cavity; 
and by rupture may produce copious hemorrhage, which may prove 
fatal. 




Fig. 77. — Roentgenogram. The special features of this picture are the prominent 
bronchi, showing induration; the diffuse shadows throughout the lungs, indicating tuber- 
culosis; small tent-like raised areas in the diaphragm, indicating pleural adhesions and 
the large right heart. (From Brown.) 

Cavities of moderate size by coalescence often lead to the 
formation of extensive excavations which, in exceptional in- 
stances may embrace the greater portion of a lobe. 



DISEASES OF THE LUNGS 



137 



When the peripheral portions of the lung are involved, a cav- 
ity may form just subjacent to the pleura, and by rupture through 
that membrane produce pneumothorax. In other instances, in- 
stead of rupturing with the formation of a fistulous communica- 
tion between the lung and pleural eavity, adhesions may form 




Fig. 78. — Lung. Chronic phthisis, showing a large irregular cavity in the upper 
lobe. In the lower lobe there are scattered acute nodules grouped in clusters around 
the small bronchi; and also several small more acute cavities. The bronchial glands 
are enlarged and caseous. (Edinburgh University Anatomical Museum.) (Woolley after 
Beattie and Dickson.) 



138 PHYSICAL DIAGNOSIS 

between the visceral and parietal pleura, as the result of local- 
ized pleurisy overlying the tuberculous lesion in the lung. These 
pleural adhesions are frequently quite extensive, to a great 
extent serving to immobilize the lung. 

Instead of undergoing caseation and softening with consequent 
cavity formation, tuberculous foci in the lung may undergo a 
process of sclerosis. Sclerosis is a reparative process, tending to 
inhibit the spread of infection ; but it is rare for sclerosis to oc- 
cur to an extent sufficient to save a tuberculous lung. Lime salts 
may be deposited in sclerotic and caseous foci and limit the 
spread of the infection temporarily ; but an attack of a bronchial 
affection such as influenza is prone to " light up" these dormant 
or residual foci of infection. 

The bronchial glands do not escape the tuberculous infection. 
Infiltration, caseation, abscess formation and rupture of the 
glands frequently are seen. 

Physical Signs. — Inspection. — Chronic ulcerative phthisis pro- 
duces a characteristic deformity of the thorax in its later stages, 
the phthisical or paralytic thorax. It may be noted that the de- 
gree of expansion of the chest upon the diseased side is deficient, 
this deficiency being first noted in the infra-clavicular region. If 
the left lung is diseased, the cardiac impulse shows a wide impulse 
in the second, third, and fourth interspaces. There is abolition of 
Litten's phenomenon on the diseased side. In not a few instances 
the pupil corresponding to the side of the disease is found dilated, 
probably owing to pressure upon the cervical sympathetic fibers. 
(See Fig. 26, p. 45.) 

The subject of chronic ulcerative phthisis is dyspneic, which may 
be caused by the rapid extension of the disease with involvement of 
both lungs, to associated emphysema, or to right heart failure. 
Emaciation is a marked feature of chronic ulcerative phthisis, the 
muscles of the shoulder girdle wasting rapidly. (See Fig. 47, p. 72.) 

Localized retractions of the chest wall are often noted, indicat- 
ing areas of pulmonary collapse or the traction of pleural ad- 
hesions overlying tuberculous lesions of the lung. The finger- 
tips are often clubbed (Hippocratic fingers). 

Many cases of chronic ulcerative phthisis, even in their in- 
cipiency will exhibit an abnormal flattening and mobility of the 
sternal angle (Rothschild's Sign); while in other cases there is 
early ankylosis and rigidity of the spinal column in the dorsal 
region (Lorenz's Sign). 

Uni-lateral deficiency of expansion is noted first as a lagging 



DISEASES OF THE LUNGS 



139 



inflation of one or both apices, later affecting the infra-clavicular 
and mammary regions, the uni-lateral deficiency being compen- 
sated for by vicarious expansion of the undiseased lung. 





Fig. 79A. — Illustrating marked regional degeneration of the muscles and other soft 
tissues over the anterior surface of the chest as a result of chronic tuberculosis. 
The lesion is older and more extensive on the right side. The degeneration of the 
soft tissues on the right is particularly marked. The lowering of the angle of the 
trapezius is well shown both anteriorly and posteriorly: so is the degeneration of the 
right sterno-cleido-mastoideus as compared with the left. (.From Pottenger.) 



140 



PHYSICAL DIAGNOSIS 





Fig. 79B. — Same as Fig. 79A, showing posterior view. The right trapezius and 
other soft tissues are wasted more than those on the left, and permit the shoulder 
to drop markedly. (From Pottenger.) 



DISEASES OF THE LUNGS 



141 



The sputum of chronic ulcerative phthisis is characteristic. 
Scanty and almost purely mucoid in the early stages of the dis- 
ease, later the sputum becomes abundant, muco-purulent or puru- 
lent, containing leukocytes, epithelum, elastic fibers, the tubercle 
bacillus and various other bacteria. Small yellowish caseous 




*s$ y 




r 






* 



i 




Fig. 80. — Illustrating the distortion of the thoracic viscera in a patient with a 
marked destructive lesion in the right lung, and marked compensatory changes in the 
left. A, the upper lohe on the right, is a small fibroid mass; B, the middle lobe, is only a 
fibrous string; C, the lower lobe, barely presents anteriorly, but posteriorly was the 
seat of emphysema; D, three-fourths of the heart lies to the right of the median line: 
E, the upper lobe on the left represents a large portion of the lung which presents 
anteriorly. A new lobe has been formed, pushing through the anterior mediastinum 
to a distance of three inches beyond the median line; F, the lower lobe is also markedly 
emphysematous; G, trachea. (From Pottenger.) 



masses are frequently found in the sputum, which are most inti- 
mately associated with the tubercle bacillus. Occasionally the 
sputum is blood tinged or contains free blood. Hemoptysis is a 



valuable sign of the disease. 



142 PHYSICAL DIAGNOSIS 

Palpation confirms the findings of inspection as to deficiencies of 
expansion of the thorax and may bring to light slight deficiencies 
which have escaped detection during visual examination. Palpa- 
tion is particularly to be recommended in the detection of slight 
deficiencies of expansion at the apices in incipient cases. To de- 
tect lagging inspiratory filling of the apices the examiner should 
stand behind the patient and palpate the apices with the thumbs 
in the supra-clavicular and the fingers in the infra-clavicular 
fossae. (See Fig. 37, p. 57.) 

Over densely infiltrated or consolidated areas of the lung vocal 
fremitus is exaggerated. It is particularly exaggerated over su- 
perficial cavities with bronchial communication. Great pleural 
thickening or exudate, or pleural effusion coexisting with the dis- 
ease may obscure the fremitus or entirely abolish it. More rarely 
there may be pleural friction fremitus and rhonchal fremitus. 

In view of the fact that vocal fremitus is normally more intense 
over the right apex than it is over the left, an equalization of the 
degree of vibration over both apices would point to consolidation 
of the apex of the left lung. 

The pulse is usually moderately increased in rate, but not out 
of proportion to the fever. 

, Percussion. — In eliciting slight degrees of dullness in incipient 
cases the examiner should direct the patient to inspire to the full 
capacity and then to suspend respiration, while he carefully per- 
cusses the apices of the lungs. Dullness in this locality is indica- 
tive of apical consolidation. In eliciting dullness in the apices it is 
Well also to employ immediate percussion by tapping the clavicle 
upon each side and noting any discrepancy in the notes elicited. 
Also in examining for dullness over the bases posteriorly immediate 
percussion is useful, the examiner slapping the sides of the chest 
alternately with the palm of the hand. 

Percussion over a tuberculous cavity elicits a tympanitic or 
cracked-pot sound; and the signs of Wintrich, Friedreich, and 
Gerhardt can usually be elicited. (See Fig. 65, p. 86.) 

Upon percussion of the pectoral muscles a sudden contraction 
of the muscle under examination may be noticed (Myoidema), 
which merely indicates that atrophy is progressing rapidly and is 
not pathognomonic of pulmonary tuberculosis. 

In cases of suspected chronic ulcerative phthisis the inter- 
scapular regions around the level of the 5th dorsal spine should 
be percussed, and the quality of the note elicited on the two sides 
compared. 



DISEASES OF THE LUNGS 143 

Percussion of a lung the scat of chronic ulcerative phthisis may 
yield tympany in the absence of cavity formation, provided that 
mi area of firm consolidation is immediately under the percus- 
sion blow and reaches down to a large bronchus. Jn such a case 
the tympany of the bronchus is transmitted readily to the surface 
of the chest. 

Auscultation. — Auscultation of the lungs usually affords the 
earliest information as to the presence of chronic ulcerative phthisis. 
In the very early stages of the disease the respiratory murmur is 
feeble, and there is recognized the jerky respiration or coo-wheel 
breathing, in which during inspiration the murmur is interrupted 
at several points, producing a sound somewhat similar to that of a 
sobbing child. Rarely in the early course of the disease a pleural 
friction sound is audible. (See Fig. 67, p. 92.) 

One of the earliest signs of the disease is the crepitant rale. 
As the consolidation increases the breath sounds become broncho- 
vesicular and finally bronchial, associated with increase of vocal 
resonance, bronchophony or pectoriloquy. A pulmonary cavity 
frequently is indicated by the development of whispering pec- 
toriloquy, or cavernous or amphoric breathing. A cavity filled 
with secretion, or one whose bronchial communication is plugged 
gives forth no physical signs. But when such a cavity is only 
partially filled, there are moist and gurgling rales, with rarely 
the metallic tinkle or succussion sound, if the cavity be of suffi- 
cient size and favorably situated. 

The presence of the lung-fistula sound indicates that pneu- 
mothorax has been produced by rupture of a sub-pleural cavity. 

The mucous click, a sharp clicking sub-crepitant rale, may be 
heard in certain advanced cases, and is said to indicate rapid 
softening. 

Diagnosis. — Chronic ulcerative phthisis in its evolution and 
course produces a multiplicity of physical signs ; but in the diag- 
nosis of the disease no sign, however slight or insignificant it may 
appear in itself, should be overlooked. The greatest difficulty in 
reaching a diagnosis arises in the incipient cases ; and it is in just 
these cases, where the chance of recovery from the disease has 
not absolutely passed, that it is most important to diagnose the 
disease. 

Signs and symptoms pointing to the presence of chronic ulcer- 
ative phthisis are emaciation, anemia marked in degree, fever, a 
symptom which is always present; night sweats, cough, pain in 
the chest, dyspnea and hemorrhage. Add to this the characteris- 



144 PHYSICAL DIAGNOSIS 

tically deformed chest, the hectic flush of a well established case 
and the diagnosis is very probable. A history of the disease in 
the parents, or the discovery of a tuberculous focus somewhere in 
the body are very suggestive. The diagnosis is confirmed by the 
finding of the tubercle bacillus in the sputum. In young patients 
the tuberculin reaction may be of value. 

In interpreting the physical signs especial emphasis should be 
laid upon areas of deficient expansion, dullness at the apices, harsh 
and prolonged expiration, and rales which persist and are re- 
peatedly audible in the same area. 

Malaria may be simulated by the fever of chronic ulcerative 
phthisis, with chills and sweats; but the blood is negative for the 
malarial Plasmodium, and the sputum shows usually the tubercle 
bacillus ; and there is usually a family history of the disease in some 
member of the family. 

Consolidations of the lung due to lobar or catarrhal pneumonia 
are differentiated from that of tuberculosis by the absence of sputum 
containing tubercle bacilli, and the clinical course of these 
diseases. 

Bronchiectatic cavities, pulmonary abscess, or gangrene, while 
they may give rise to physical signs suggestive of tuberculosis, are 
differentiated by the absence of the tubercle bacillus in the sputum. 

FIBROID PHTHISIS 

Pathology. — Fibroid phthisis is a chronic form of pulmonary 
tuberculosis, in the evolution of which the predominant feature 
is the formation of an excessve amount of fibrous connective tis- 
sue. The disease may arise in one of two ways. Thus, the tuber- 
culous infection may be primary, and through the process of re- 
parative sclerosis may assume the fibroid type. On the other 
hand, the tuberculous process may be engrafted upon a lung 
previously fibrosed, either by pneumonokoniosis or chronic inter- 
stitial pneumonia following upon a fibrinous pneumonia which has 
healed by sclerosis or a pleurogenous interstitial pneumonia. 

In the cases which are primarily tuberculous, the disease starts 
in an apex of one or both lungs; and, as in other forms of the 
disease, progresses downward, involving the lower lobes suc- 
cessively. In this class of cases one apex may be sclerosed or the 
entire lung may be sclerotic and shrunken, showing cavities and 
bronchial dilatations either open or filled with caseous material. 

In many instances the only way to determine whether a pul- 



DISEASES OF THE LUNGS 145 

monary fibrosis is tuberculous or non-tuberculous, is by the pres- 
ence or absence of tubercle bacilli in the sputum ; but in other 
cases there are areas of tuberculosis demonstrable in various areas 
of the cirrhotic lung at autopsy. 

The distribution of the fibrosis is largely influenced by the man- 
ner of inception of the disease. Thus, in cases arising from in- 
halation through the bronchi the formation of connective tissue is 



Fig. 81. — Illustrating schematically the displacement of the heart to the left. It 
will he seen that the left half of the diaphram is pushed upward, and the apex of 
the heart follows the fifth interspace. This displacement has a tendency to reduce the 
curve in the arch of the aorta. The trachea may be drawn entirely to the left of the 
median line as shown in the cut. (.From Pottenger.) 

most pronounced around the bronchi and bronchioles; whereas 
in the cases arising as a result of tuberculous pleurisy the periph- 
eral portions of the lungs are most extensively involved. 

The lung is frequently pigmented, is shrunken, and occupies a 
very small portion of the pleural cavity near the spinal column. 

Physical Signs. — Inspection. — The signs of this disease are al- 



146 PHYSICAL DIAGNOSIS 

most identical with those of chronic interstitial pneumonia. The 
affected side is shrunken, the shoulder droops, there is deficient ex- 
pansion, and areas of local retraction of the chest wall are common. 
The cardiac impulse is displaced toward the side of the disease. In 
left-sided disease there is apt to be a wide visible impulse in the 
third, fourth, and fifth interspaces ; while in disease of the right 
lung the impulse may be displaced behind the sternum. There -is 




Fig. 82. — Illustrating schematically marked displacement of the heart to the right. 
It will be noticed that the heart is pushed upward and over. The right side of the 
diaphragm assumes a high position; while the left side assumes a low one in order to 
accommodate the left lung which is the seat of compensatory emphysema. When this 
displacement is present, the curve in the arch of the aorta is lessened with a tendency 
to pouching. (From Pottenger.) 

frequently scoliosis, with the convexity of the curve toward the side 
of the disease. The intercostal spaces are narrowed, the ribs some- 
times overlapping. The fossa? in the supra- and infra-clavicular 
regions are abnormally deep while the clavicles stand out promi- 
nently. The expansion of the sound side of the chest in uni-lateral 
disease is increased as a result of compensatory emphysema. 



3ES OF THE LUNGS 



147 



Palpation sometimes reveals slight degrees of deficient expansion 
which have escaped observation during inspection. The vocal 
fremitus varies in intensity with the condition of the lung and 
pleura, palpation over cirrhotic lung tissue adjacent to the chesl 
wall and over cavities giving increased vocal fremitus; while pleural 
thickening or retraction of the lung yields a fremitus of diminished 
intensity. Similarly, if the fibrosis is centrally situated and over- 
laid by normal pulmonary tissue, the fremitus is diminished, or at 
least is not exaggerated. Over the sound side, jn uni-lateral dis- 
ease, the fremitus is diminished and the expansion increased. 

Percussion. — Percussion over the apices usually gives a dull or 
flat note over the diseased side. A cavity in the apex is indicated by 








Fig. 83. — Showing schematically the compensation which has taken place between tin 
two sides of the chest, and between the thoracic and abdominal cavities. A, anterior view 
B, posterior view. (From Pottenger.) 



hyper-resonance or tympany. A greatly thickened pleura or over- 
lapping of the ribs gives a flat note accompanied by a marked sense 
of increased resistance. A small area of hyper-resonance or tym- 
pany at the base of the lung is indicative of a cavity or bronchial 
dilatation. Percussion of the sound lung, in uni-lateral cases, yields 
a hyper-resonant note. 

Auscultation. — Over the apex there is bronchial, occasionally 
amphoric or cavernous breathing. At the bases there is often dis- 
tinct bronchial breathing, provided the lung is not retracted up into 
the upper portion of the pleural cavity, in which event the breath 



148 PHYSICAL DIAGNOSIS 

sounds are absent or feeble. Amphoric or cavernous breathing aris- 
ing in any region of the thorax are indicative of pulmonary cavity 
or bronchial dilatation. The rales of chronic bronchitis are often 
encountered. The pulmonic second sound is accentuated, and in 
late cases is enfeebled, with the presence of the tricuspid relative 
systolic murmur. 

Diagnosis. — The deformity of the chest, the wide area of the 
cardiac impulse, the bronchial and amphoric breath sounds over an 
apex with dullness or flatness, indicate fibrosis of the lung with 
cavity formation. "Whether or not this is tuberculous is deter- 
mined by the examination of the sputum for the tubercle bacillus. 
But in fibroid phthisis, in contra-distinction to fibrosis from other 
causes, the disease is apt to be bi-lateral, whereas in other in- 
stances it is apt to be uni-lateral. Hence careful examination of 
both lungs should be made for the purpose of detecting signs of 
disease in an apparently sound lung. 

PULMONARY SYPHILIS 

Pathology. — Syphilis attacks the lungs in two forms: as heredi- 
tary syphilis, and as acquired syphilis of the lung. 

Hereditary syphilis of the lung was first described by Virchow 
as pneumonia alba. The lung in hereditary syphilis is enlarged, 
showing on its external surface indentations corresponding with 
the ribs with which it is in contact. The lung is white or slightly 
tinged with yellow, is firm, and upon section the cut surface re- 
sembles macroscopically a section of pancreatic tissue, a condi- 
tion to which Lorain and Robin have applied the term "pan- 
creatization. ' ' 

Microscopically the inter-alveolar septa show an overgrowth of 
fibrous connective tissue, leading to thickening of the alveolar walls, 
the alveolar spaces being smaller than normal and densely filled 
with desquamated epithelium, cellular detritus, and fat. Hoff- 
man called attention to a thickening of the vascular walls in the 
inter-alveolar septa, analogous to that which occurs in syphilitic 
fetal tissue elsewhere, the vessels often presenting evidences of 
hyaline degeneration. 

The lesions of acquired syphilis of the lung may assume three 
types, one or all of which may be present in a given case ; namely, 
gummata, interstitial sclerosis analogous to chronic interstitial 
pneumonia from other causes, and syphilitic broncho-pneumonia. 

The gummata are situated deeply near the root of the lung, 



DISEASES OF THE LUNGS 



149 



varying in size from a hazelnut to a hen's egg or larger. They 
are apt to soften and break into a bronchus or undergo sclerosis 
and by traction lead to bronchiectatic dilatations. Gummata are 
the rarest of syphilitic lesions of the lungs. Wagner and Henop 
described gummata in both the upper and lower lobes of the lung, 
situated chiefly toward the root, usually containing in their center 
a dilated bronchus with chronically inflamed mucous membrane. 
The lung intervening between the gummata was partially crepi- 
tant while the apices and anterior borders of the lungs Avere in a 
state of compensatory emphysema. 

The interstitial sclerosis attending acquired syphilis of the lung 
has its inception near the root of the lung, and extends thence in 
various directions between the alveoli. The patches of insular 




Fig. 



84. — Pneumonia alba of newborn. (From McFarland.) 



sclerosis often extend in all directions from gummata situated near 
the pulmonary root, dividing the lung into a number of divisions 
or lobules. Traction diverticula are formed and lead to bron- 
chiectatic cavities. 

The broncho-pneumonia of syphilis does not differ essentially 
from broncho-pneumonia from other causes, Pavlhioff describing 
a bi-lateral syphilitic broncho-pneumonia with patches of con- 
solidation interspersed betAveen areas of normal tissue in both 
lungs. The alveoli are filled with desquamated epithelium, leuko- 
cytes, and erythrocytes, the pneumonic patches being dull slate- 
colored on section. 

Physical Signs. — Hereditary syphilis of the lung must in cer- 
tain instances be differentiated from atelectasis, which it closely 



150 PHYSICAL DIAGNOSIS 

simulates; but there are sufficient evidences of hereditary syphilis 
elsewhere upon the body as a rule to make the diagnosis clear. 

The physical signs of acquired syphilis are not characteristic, 
the picture being often that of chronic interstitial pneumonia from 
other causes, chronic ulcerative phthisis, or ordinary broncho- 
pneumonia. However, there are certain localizations of the prin- 
cipal signs emanating from pulmonary syphilis which are of con- 
siderable aid in diagnosis. Thus, the lesions are usually situated 
near the root of the lung, gummata and sclerosis in this situation 
giving rise to dullness on percussion and bronchial breath sounds 
upon auscultation along the lateral sternal borders, over the roots 
of the lungs, which signs decrease as the examiner passes outward, 
upward, and downward from these locations. Grandidier lays 
great emphasis upon the localization of the physical signs in these 
regions of the thorax, while Pankritius points out the importance of 
dullness in the interscapular regions at the same level. 

The affection produces chronic cough, often attended by hemop- 
tysis, and fever, simulating chronic ulcerative phthisis ; but there 
can often be found evidences of syphilis in other regions of the 
body, and the specific tests for syphilis are positive. 

PNEUMONOKONIOSIS 

Pathology. — Pneumonokoniosis is a chronic induration of the 
lungs due to inhalation of various kinds of dusts and mineral par- 
ticles. Depending upon the nature of the exciting cause the dis- 
ease is subdivided into a number of different forms: siderosis, 
from the inhalation of iron filings; chalicosis, from the inhalation 
of stone particles; anthracosis, from the inhalation of coal dust. 
Similar pulmonary changes ensue upon the continued inhalation of 
fibers of wool, flax, cotton, tobacco, glass, bone, or horn. 

Anthracosis, caused by the continued inhalation of coal dust, is 
termed "coal miner's disease." The minute amounts of this dust 
usually inhaled is absorbed by the leukocytes which reside upon 
the surfaces of the respiratory passages ; are carried upward by 
the action of the ciliated epithelium of the tract, and expectorated. 
When the dusts are inhaled in larger amount, however, some of 
the coal particles penetrate the bronchial mucous membrane and 
find lodgment in the connective tissue, or enter the lymph stream 
and are carried to the smaller lymphatic glands around the blood 
vessels, the bronchi, the plura, or in the mediastinum. The lungs 
of all dwellers in cities are moderately pigmented from the in- 



DISEASES OF THE LUNGS 



151 



halation of coal dust and soot, while the lungs of persons who 
have lived all their days in the open country, remote from Large 
manufacturing industries, are often pink in color and free from 
this pigmentation. 

When the soot or coal dust is inhaled in very Large quantities, 




Fig. 85. — Anthracosis. (From Delaheld and Prudden.) 



152 



PHYSICAL DIAGNOSIS 



a portion of it reaches the alveoli. In lungs the seat of this ex- 
treme grade of anthracosis the organs are distinctly black. The 
irritation of these grains of dnst in the interstices of the tissues 
excites the growth of connective tissue and a connective tissue 
proliferation occurs leading to fibrosis in insular foci. On section 
these fibrosed areas are hard to the touch and exude a black fluid. 
Diffuse induration of an entire lung or the greater portion of a 
lung is common. 

The bronchial and mediastinal lymph glands are indurated, 
and often the seat of periadenitis by virtue of which they ad- 
here to the adjacent large vessels and by rupturing into the same 
distribute pigmentation to various organs of the body, as the 
liver, spleen, kidneys, and mesenteric lymphatic glands. 




Fig. 86. — Pulmonary anthracosis. (From McFarland.) 



Bronchial perilymphadenitis may lead to adhesions between the 
glands and the pericardium, producing a mediastinopericarditis. 
Adhesions may form between these glands and the esophagus, and 
lead to diverticulum of that tube. Adhesions may form between 
the glands and the aorta and cause erosion of that vessel with 
fatal hemorrhage. Adhesive bands may constrict the trachea or 
vessels and lead to tracheal or vascular stenosis or narrowing. 
They may lead to aspiration pneumonia when a gland erodes a 
bronchus and discharges its contents by that avenue. Finally, the 
inflamed mediastinal glands may produce vagus or recurrent laryn- 
geal nerve paralysis by pressure upon these nerves. 



DISEASES OF THE LUNGS 153 

Chalicosis, due to inhalation of alumina, quartz, or sandstone, 
is known as "stone-cutter's phthisis," "mill-stone maker's phthi- 
sis," "grinder's rot," or "potter's asthma." Chalicosis produces 
more induration of the lung than does am r other form of pneu- 
monokoniosis. 

Siderosis is a fibrosis of the lung due to the inhalation of iron 
filings or dust. The changes in the lungs and mediastinal and 
bronchial glands are similar to those accompanying anthracosis. 
But the induration is more intense than it is in anthracosis. 

The areas of localized induration which are formed throughout 
the lungs in some instances undergo softening and form pul- 
monary cavities. In other instances the softening is due to sub- 
sequent infection with the tubercle bacillus; though as a rule the 
pneumonokoniotic lung does not seem to prove a fertile field for 
the ravages of the tubercle bacillus. As a result of the chronic 
inflammation set up by the continual aspiration of the irritant 
dusts the bronchial tubes show a chronic bronchitis, which is fol- 
lowed by emphysema, while the lung slowly undergoes a slow in- 
sular sclerosis. 

Physical Signs. — The physical signs of pneumonokoniosis are 
modified and influenced by the coincident chronic bronchitis, em- 
physema and interstitial sclerosis, with occasionally signs of cavity 
engrafted upon these signs. Signs of cavity suggest chronic ulcer- 
ative phthisis or bronchiectasis, and it should be remembered that 
both diseases are possible complications. In a typical case of 
pneumonokoniosis the physical signs are evolved with a fair de- 
gree of regularity. The earliest signs to become appreciable are 
those of a chronic bronchitis; then there appears the picture of 
a gradually developing hypertrophic emphysema; and finally 
signs of chronic interstitial pneumonia become evident, with or 
without signs of bronchiectasis or tuberculous cavities. 

The sputum is of aid in diagnosis. In anthracosis it is black 
from the content of coal dust; in siderosis it is reddish or brown; 
while in chalicosis the shining particles of stone can be seen mi- 
croscopically. 

Diagnosis. — The diagnosis is made by obtaining a history of an 
occupation requiring the long continued inhalation of dusts, and 
physical signs of chronic bronchitis, emphysema, and cirrhosis of 
the lung, with or without evidences of cavity formation, and the 
characteristic sputum. Late in the disease the sputum may con- 
tain tubercle bacilli from tuberculous infection. 



154 PHYSICAL DIAGNOSIS 



ATELECTASIS 



Pathology. — Imperfect expansion of the lung or partial collapse 
of a lung which has become expanded may be congenital or ac- 
quired. In the congenital form of atelectasis the lung has never 
been properly expanded; while in the acquired form, which is a 
disease of later life, there occurs from various causes a partial 
collapse of the lung. 

Congenital Atelectasis is a disease of the newly born, develop- 
ing usually as a result of insufficient inflation of the lung due to 
the aspiration of meconium or mucus during parturition, or from 
weakness of the respiratory muscles subsequent to birth. In 
atelectatic children who survive, the anterior borders and upper 
lobes of the lungs are partially expanded, while the central and 
lower portions of the lungs are brownish red, vascular, and fail 
to crepitate upon manipulation. 

As the child gains strength the anterior and upper portions of 
the lungs become emphysematous from compensatory emphysema, 
while the deeper portions are very slow to inflate. Congenital 
atelectasis is bi-lateral, involving both lungs, and usually to a 
similar degree. 

It is probable that the central portions of the lungs of atelec- 
tatic children never attain to full inflation, as the tendency is 
rather for secondary changes to occur, leading to sclerosis and 
contraction of the deeper elements of the lung. 

Acquired Atelectasis is often the result of compression of the 
lung by a pleural effusion, a tumor, aneurism, or deformity of 
the thoracic wall. The most fertile cause of the condition, how- 
ere, is bronchial obstruction from foreign bodies, or external pres- 
sure of a tumor or aneurism. Similarly in severe cases of capillary 
bronchitis or broncho-pneumonia the terminal alveoli are ob- 
structed by exudate and lead to circumscribed areas of atelectasis. 
In conditions of great debility the result of malnutrition or lying 
long in the recumbent posture with an exhausting disease some- 
times induces areas of atelectasis. 

The atelectatic area of the lung is darker than normal, is de- 
pressed, and is usually distributed in a number of areas cor- 
responding to lobules of the lungs. On section the areas are 
usually dry, but may be moist from chronic passive congestion. 

Physical Signs. — The physical signs of atelectasis are influ- 
enced and varied by the manifestations of the disease or condi- 
tion which has given size to the atelectatic state of the pulmo- 



DISEASES OF THE LUNGS 155 

nary 1 issues. The signs also vary in intensity and number with 
the volume of lung involved in the atelectasis and the condition 
of the undiseased portion of the pulmonary system. It is ob- 
vious that the physical signs arising from collapse of an entire 
lung will differ markedly in degree from those referable to a 
few scattered areas of collapse in one or both lungs. 

Inspection. — Extensive atelectasis, involving a considerable area 
of a lung gives rise to dyspnea and sometimes to cyanosis, with 
inspiratory retraction of the intercostal spaces and epigastrium, 
with defective expansion of the side corresponding to the disease. 

Palpation. — Vocal fremitus over the area of disease may be di- 
minished, absent, or exaggerated, depending upon the state of 
the pulmonary parenchyma. Collapsed, toneless pulmonary tis- 
sue fails to conduct the vocal vibrations with the normal in- 
tensity, and if a main bronchus be completely obstructed, there 
will be an absence of vocal fremitus over the distribution of the 
bronchus. However, when secondary changes have set in in a 
case of atelectasis with partial broncho-stenosis the fremitus is 
transmitted with increased intensity. Pleural friction fremitus 
is occasionally demonstrable due to involvement of the pleura 
over the atelectatic area. 

Percussion. — The dullness produced by small patches of ate- 
lectasis is masked by the hyper-resonance of the adjacent em- 
physematous lung tissue. An area of atelectasis must be large 
and superficially situated to give dullness upon percussion. A 
patch directly overlying a large bronchus yields the tympany 
of the bronchus upon percussion. Deeply seated areas of ate- 
lectasis fail to give dullness, owing to the intervention of the 
normal tissues between the area of disease and the thoracic 
wall. 

Auscultation. — The vesicular murmur is feeble or abolished 
over an atelectatic area, unless the area overlies a large 
bronchus, when the murmur will be broncho-vesicular or purely 
bronchial. In non-extensive areas of atelectasis the only aus- 
cultatory phenomena may be a few rales upon deep inspiration. 

In the atelectasis which develops at the bases of the lungs in 
patients who have long been in the recumbent posture full in- 
spiration will reveal crepitant rales, owing to the fact that the 
alveolar Avails which have become adhered with sticky serum 
are opened up and separated upon full inspiration. 

The pulmonary second sound is accentuated in cases of ex- 
tensive atelectasis. 



156 PHYSICAL DIAGNOSIS 

In cases of congenital atelectasis the chief signs are marked 
dyspnea and cyanosis of moderate intensity, with inspiratory 
retraction of the lower interspaces, with cold extremities and 
attacks of syncope without apparent cause. 

Diagnosis .—The diagnosis of pulmonary atelectasis is often 
for a time difficult or impossible. The finding of respiratory em- 
barrassment and the location of some adequate causative lesion 
such as bronchial obstruction or pulmonary compression is sug- 
gestive. The physical signs are seldom clear-cut and distinctive, 
as small areas of collapse have their physical signs masked by 
the emphysematous condition of the surrounding lung. More- 
over, as a larger area of collapse is apt to overlie a bronchus 
and have its tympanitic note engrafted upon the dullness of the 
atelectasis a pulmonary cavity may be suspected where none 
exists. The fact that the physical signs have a tendency to im- 
prove and to regress with changes of posture and deep infla- 
tion of the lungs is suggestive. 

HYPERTROPHIC EMPHYSEMA 

Pathology. — Hypertrophic emphysema, idiopathic or substan- 
tive emphysema, or the large-lunged emphysema of Jenner, is a 
condition of the lungs in which they are enlarged, their air cells 
greatly distended with air, and the inter-alveolar septa thinned 
and atrophic. It is also known by the names chronic or diffuse 
emphysema. 

The disease is usually encountered in patients who suffer with 
chronic bronchitis or persons whose occupations require expira- 
tion with the glottis closed, as in glass-blowers, and players 
upon wind instruments. It is probable that impaired nutrition 
of the alveolar walls with the result that the elastic tissue is un- 
able to contract and expel the air from the infundibula plays a 
part in the production of the disease. Freund's theory of the 
cause of hypertrophic emphysema assumes that it is primarily a 
disease of the costal cartilages; that there is a chronic hyperplasia 
of these cartilages, which ossifying prematurely, cause the chest 
wall to lose its elasticity, the emphysematous condition of the 
lungs developing as a result of lack of support. 

Hypertrophic emphysema is bi-lateral, both lungs being in- 
volved to a similar extent. The distention of the lungs is gen- 
eral and universal in all directions, but it is most marked in the 
anterior borders, which, overlapping the heart, give rise to a 



DISEASES OF THE LUNGS 



157 



diminution of the area of that organ which is in contact with the 
anterior chest wall. The lungs are enlarged, are pale, are light 
and feathery to the touch and do not collapse readily when the 
chest is opened. 

Under the microscope the air cells are observed to be very 
large, distended, and that in many instances the inter-alveolar 
septa have become atrophied and ruptured, forming larger cav- 
ities by the coalescence of several air spaces. With the destruc- 
tion of the inter-alveolar septa the capillaries which they sup- 




Fig. S7. — Pulmonary capillaries. The walls of the alveoli are thickly studded with 
capillaries; any marked alteration of alveolar air tension will therefore have a profound 
effect upon the circulation. (Brown, after Bohm, Davidoff, and Huber.) 



ported are destroyed, and the quantity of blood exposed to the 
air in the lungs is commensurately diminished, resulting in de- 
ficient oxygenation of the tissues, cyanosis and dyspnea. 

The pleura covering the lung loses its pigmentation in patches, 
a condition which was termed by Yirchow Albinism of the lung. 
The bronchi and bronchioles show signs of bronchitis, and bron- 
chiectatic dilatations are common. (See Fig. 74, p. 129.) 

The right side of the heart is hypertrophied, due to the increased 



158 PHYSICAL DIAGNOSIS 

load thrown upon it, and the tricuspid ring is usually enlarged, so 
that the valve segments often fail to close the orifice. 

Rupture of the thinned lung may lead to the production of 
pneumothorax. 

Physical Signs. — Inspection. — Hypertrophic emphysema pro- 
duces a definite alteration in the shape of the chest, the barrel- 
chest of this disease. In this chest the antero-posterior diameter 
is increased often to such a degree that it equals or exceeds the 
transverse diameter. The expansion of the chest is minimal, the 
thorax rising and falling as one piece. The expiratory move- 
ment is much longer than is the inspiratory effort. 

The cardiac impulse is often invisible, and there is often seen 
epigastric pulsation, while pulsations of the jugular veins are 
common. In the late stages with a failing heart, the patient 
shows dyspnea, and not infrequently is cyanotic. Not infre- 
quently there is a delicate tracery of distended veinules over the 
lower portion of the thorax produced by intra-thoracic obstruc- 
tion to the venous flow. (See Figs. 20 and 21, pp. 41 and 42.) 

The facies of hypertrophic emphysema is fairly characteristic. 
The eyes are slightly prominent, the nose is somewhat thickened 
and cyanotic; while the head is thrown backward slightly in the 
effort to bring the accessory muscles of respiration into play. The 
neck is short and thick with prominent sterno-mastoids and tra- 
pezii. 

Litten's diaphragmatic shadow is abolished; there is chronic 
cough ; and the finger-tips are clubbed. 

Palpation. — Vocal fremitus is diminished over both sides of the 
chest. In cases with marked bronchitis rhonchal fremitus is oc- 
casionally encountered. The cardiac impulse is rarely palpable, 
owing to the intervention of the emphysematous anterior borders 
of the lungs between the heart and chest wall. A systolic impulse 
in the epigastric region, owing to overaction of the right ventricle 
is readily palpable. The liver is seldom displaced sufficiently for 
its lower border to be freely palpated below the right costal arch ; 
but in late cases when the right heart is failing, palpation of the 
liver reveals the systolic pulsation of tricuspid regurgitation. 

The spleen is seldom displaced in hypertrophic emphysema. In 
late cases palpation of the abdomen may show the presence of 
moderate ascites. 

Palpation reveals the deficient expansion of the thorax, the 
hard costal cartilages, and the rigidity of the muscles of the neck. 

Percussion yields a hyper-resonant note over both lungs, the 



DISEASES OF THE LUNGS 159 

limits of pulmonary resonance being increased in all directions. 
The area of cardiac dullness is restricted by the emphysematous 
anterior borders of the lungs. Percussion may be employed in 
detecting downward displacement of the liver, and the presence of 
ascites by eliciting dullness in the flanks with tympany in the 
median line of the abdomen. 

The respiratory excursion of the lungs, determined by per- 
cussing out the lower borders of the lungs during expiration and 
inspiration, is very slight in hypertrophic emphysema, rarely ex- 
ceeding half an inch. 

Auscultation. — The respiratory sounds are feeble, with prolonga- 
tion of the expiratory phase. The expiratory murmur is harsh, 
and not infrequently dotted with rales due to chronic bronchitis. 
The inspiratory murmur is always short, and may be entirely in- 
audible. Vocal resonance, like vocal fremitus, is impaired. 

The heart sounds as a whole are diminished in intensity, owing 
to the intervention of the distended anterior borders of the 
lungs between the heart and chest wall. Of the individual 
sounds, the pulmonic sound is accentuated, owing to the obstacle 
to be overcome in the pulmonary circulation. 

Diagnosis. — The diagnosis of hypertrophic emphysema can 
often be made at a glance. It rests upon the characteristic de- 
formity of the chest, associated with dyspnea or cyanosis, per- 
sistent chronic cough, the short or absent inspiratory murmur. 
and the prolonged harsh expiratory murmur. 

Chronic Bronchitis, with its chronic cough, shortness of breath, 
and slightly prolonged expiratory murmur, may resemble hyper- 
trophic emphysema ; but this disease does not produce the typic 
barrel chest, nor does it show general extension of the areas of 
pulmonary resonance, which forms so distinctive a feature of hy- 
pertrophic emphysema. 

Pleurisy with Effusion is usually uni-lateral, and on percussion 
yields dullness or flatness instead of general hyper-resonance. It 
is usually accompanied by Grocco's sign, and aspiration shows the 
presence of fluid. 

Pneumothorax, which in the incipiency may resemble hyper- 
trophic emphysema, is a uni-lateral affection which develops rap- 
idly, giving a hollow and tympanitic note on percussion, the suc- 
cussion sound, the metallic tinkle, and the coin test, 



160 PHYSICAL DIAGNOSIS 

ATROPHIC EMPHYSEMA 

Pathology. — Atrophic emphysema, a state in which the total 
bulk of the lung is decreased, is a senile change, a part of the gen- 
eral wasting of the tissues of the body incident to advanced age. 
The disease, if such it may be styled, is associated with persistent 
chronic cough, lasting for many years, associated with chronic 
shortness of breath upon exertion. 

In the subject with atrophic emphysema the thorax is abnor- 
mally small, the obliquity of the ribs is increased, and the excur- 
sion of the thorax with respiration is very much below normal. 

The lung as a whole is smaller than normal, the pleura is deeply 
pigmented, while the pulmonary parenchyma shows evidence of 
pulmonary congestion, edema, or infarction. The bronchial tubes 
are dilated, the dilatations being surrounded by areas ^ of in- 
duration. 

Microscopically there is atrophy and rupture of many of the 
inter-alveolar septa, permitting the formation of larger or smaller 
chambers by the coalescence of several smaller ones. The capil- 
laries are destroyed along with the inter-alveolar rupture, de- 
creasing the quantity of blood exposed to the air in the infun- 
dibula. 

Physical Signs. — Inspection. — The chest is small, the intercostal 
spaces are narrowed and pursue a more oblique course than nor- 
mally, the supra-clavicular and infra- clavicular fossae are deeper 
than normal, while the thoracic excursion is slight. The dyspnea 
of atrophic emphysema, instead of being chiefly expiratory as in 
hypertrophic emphysema, is mixed, the duration of the two phases 
being approximately equal. 

Palpation. — Vocal fremitus as a rule is slightly exaggerated 
owing to the increased density of the lungs, and the small amount 
of air contained. 

Percussion. — The limits of pulmonary resonance are decreased 
in all directions. Even within the areas of resonance as deter- 
mined by percussion there is moderate impairment of the normal 
vesicular quality of the resonance, attributable over the apices to 
fibrosis and condensation of tissue, and over the bases to edema of 
the lung. The area of cardiac dullness is extended owing to shrink- 
ing of the lung exposing a large area of the heart to the chest 
wall. The upper limits of hepatic and splenic dullness are higher 
than normal, owing to shrinking of the lnng. 

Auscultation. — The respiratory murmur is slightly impaired in 



DISEASES OF THE LUNGS 161 

intensity, rarely attaining a broncho-vesicular character. In the 
presence of chronic bronchitis, which often coexists with the em- 
physema, there are dry and moist rales. 

Diagnosis. — The diagnosis is easily made in an elderly subject 
wit li a small thorax, a generally ''dried up" appearance, chronic 
shortness of breath, and chronic cough of long duration. 

COMPENSATORY EMPHYSEMA 

Pathology. — Compensatory emphysema is the name which is 
applied to a condition in which certain portions of a lung or an 
entire lung are over-distended with air owing to a decrease in 
the air space of the same or the opposite lung. 

Compensatory emphysema may be transient <»r permanent. 
In inflammations of the terminal bronchioles with swelling of 
the mucosa, obliteration of the Lumen of the tube is produced and 
the aii- in the infundibula is prevented from escaping during ex- 
piration and leads to atrophy and rupture of the Lnter-alveolar 
septa. If the obstacle to the egress of the air persists, large 
bullae or air spaces are formed from coalescence of several con- 
tiguous infundibula and a state ot permanent emphysema is 
produced. 

A diffuse compensatory emphysema, involving an entire lung, 
usually results from massive pneumonia, chronic interstitial pneu- 
monia, or a large pleural effusion, crippling the opposite lung. 
Localized areas of compensatory emphysema occur in a lung the 
seat of atelectasis, multiple patches of consolidation as that of 
broncho-pneumonia and tuberculosis, and localized fibrosis. (See 
Figs. 80 and 83, pp. Ill and 147.) 

Physical Signs. — The physical signs of compensatory emphy- 
sema vary according to the extent of the emphysematous condi- 
tion and its size, whether involving an entire lung or merely por- 
tions of a lung, and upon the extent of lung involved. 

Inspection. — Upon inspection in a case where the entire lung is 
involved the side of the chest affected will be more prominent than 
the opposite side, which is usually shrunken owing to the crippling 
of the lung which occasioned the compensatory emphysema. Small 
areas of localized compensatory emphysema produce no alterations 
in the contour of the chest. 

Palpation. — Vocal fremitus over a uni-lateral compensatory em- 
physema is unchanged or diminished in intensity, owing to the 
rarefaction of the pulmonary tissues. 



162 PHYSICAL DIAGNOSIS 

Percussion yields a hyper-resonant note over an emphysematous 
lung; whereas in localized emphysema the note is scarcely altered. 

Auscultation shows exaggerated or puerile breathing over the 
emphysematous lung, with slight prolongation of expiration. 

Diagnosis. — A diagnosis of compensatory emphysema can sel- 
dom be made upon physical signs alone, as these are often few 
and obscure. The patient 's history should be obtained, and some 
cause which would account for a compensatory emphysema 
elicited. 

ACUTE VESICULAR EMPHYSEMA 

Pathology. — Acute vesicular emphysema is a condition in which 
the air cells of the lungs are acutely distended from expiratory ef- 
forts or fits of coughing in the presence of an obstacle to the free 
egress of air from the lungs. It is apt to develop during broncho- 
pneumonia, acute bronchitis, bronchial asthma, tracheal or bron- 
chial stenosis, and during the extreme dyspneic attacks of car- 
diac failure. 

The hyper-distention of the lungs occurs abruptly; but the air 
cells are merely distended; large cavities are not produced by 
rupture of the inter-alveolar septa as in hypertrophic emphysema ; 
for recovery ensues or death occurs ere this change takes place. 

Physical Signs. — The signs of acute vesicular emphysema are 
very similar to those of the hypertrophic form of the disease. 
There is a general extension of the limits of pulmonary reso- 
nance, the percussion note is hyper-resonant or tympanitic, and 
on auscultation there are sibilant rales distributed universally 
over both lungs, and a prolongation of the expiratory murmur. 
However, auscultation of the heart reveals no accentuation of the 
pulmonic second sound, as in hypertrophic emphysema. 

INTERSTITIAL EMPHYSEMA 

Pathology. — Interstitial emphysema is a condition in Avhich air 
or gas is present in the interlobular or interlobar septa of the 
lung or beneath the pleura. Air may gain access to these re- 
gions as a result of traumatism or violent expiratory efforts, 
when rupture of the surface epithelium occurs and gives ingress 
of air to the deeper structures. It also occurs during convul- 
sions, parturition, and while straining at stool. It may be caused 
by ulceration of the bronchi, or abscess or gangrene of the lung. 
Interstitial emphysema in the newly born has been caused during 



DISEASES OF THE LUNGS 163 

violent efforts to mechanically inflate the lungs, and has resulted 
from spasmodic closure of the glottis. 

When the air has gained access to the stroma of the lung it 
collects in the form of beads or bubbles varying in size. Some are 
very small, while others may attain the size of a walnut. These 
bubbles tend to make their way to the root of the lung and into 
the mediastinum and thence to pass upward along beside the 
trachea and to appear beneath the skin of the neck. Or the op- 
posite sequence of events may be observed. Following trache- 
otomy wounds air may enter the tissues and burrow downward 
into the root of the lun<>' and invade the stroma of these organs. 
Not infrequently the heads of air form bulla* just subjacent to the 
pleura; in which site rupture may cause pneumothorax. 

Physical Signs. — Interstitial emphysema gives rise to few phys- 
ical signs, and may escape detection entirely during a casual ex- 
amination. When the air makers its way upward and appears 
subcutaneously it may produce a protrusion, which upon being 
palpated yields a crackling crepitus. Larue heads of air beneath 
the pleura sometimes yield pleural friction sounds. 



ABSCESS OF THE LUNG 

Pathology. — Pulmonary abscess develops as a result of inflam- 
mations of the lung, as following lobar and catarrhal pneumonia, 
which do not terminate by resolution. A pulmonary abscess re- 
sulting from lobar pneumonia may occur in one of two forms. It 
may represent what is termed purulent infiltration, which merely 
represents an advanced stage of gray hepatization with tardy 
and incomplete resolution ; or there may arise the formation of 
multiple abscesses throughout the lung. But pulmonary abscess 
more frequently follows catarrhal pneumonia, particularly the 
aspiration and deglutition forms of this disease. Abscess of the 
lung is an occasional complication of influenza. 

The lodgment of foreign bodies in the bronchi sometimes pro- 
duce ulceration and consequent abscess formation. Abscess of 
the lung may result from perforation of the lung from without 
or from within. Thus it may follow a perforating gunshot wound, 
the balls carrying in with them pieces of wearing apparel or 
other germ-laden material, or it may result from puncture of the 
lung by a fractured rib. Perforation of the lung from within 
may result from extension of esophageal carcinoma, suppura- 



164 PHYSICAL DIAGNOSIS 

tion of contiguous mediastinal structures, or an abscess of the 
liver may rupture through the diaphragm. 

Infectious embolism is responsible for a large percentage of 
pulmonary abscesses. This occurs in cases of pyemia and pro- 
duces multiple abscesses usually situated beneath the pleura. 
These sub-pleural abscesses are conical in shape, with the bases 
directed toward the pleura. They are usually small, but may at- 
tain considerable size. 

Pulmonary tuberculosis in the course of its evolution leads to 
pulmonary abscess. The tuberculous abscess is well circum- 
scribed, occurs late in the course of the disease, and is associated 
with caseation and cavity formation. 

From what has been said it is evident that pulmonary abscess 
is nearly always a secondary condition, secondary to disease or 
suppuration elsewhere in the body. 

Owing to the characteristic structure of the lung suppuration 
in this organ does not always form a typical abscess with well 
defined walls; but may form a so-called purulent infiltration. In 
other instances, however, as in the tuberculous abscess, the pul- 
monary abscess has more or less well defined walls limiting the 
spread of the purulent focus. 

In size the pulmonary abscesses may be small or may be quite 
large, involving the greater portion of a lobe. In rare instances 
an abscess may involve an entire lung. The pulmonary abscess is 
usually single, but in pyemic cases multiple abscesses are formed 
throughout the lung. The shape of the pulmonary abscess is very 
irregular, and the abscess is. often divided into two or more 
loculi. The abscess is usually situated in the peripheral portion 
of the lung subjacent to the pleura, and usually occupies the 
lower lobe of the lung. 

The contents of a pulmonary abscess is purulent, containing 
shreds of elastic tissue and necrotic debris. Evacuation of a pul- 
monary abscess may occur by rupture into a bronchus, the con- 
tents being partially expectorated, the shreds of elastic tissue in 
the sputum aiding materially in diagnosis; or, if the abscess be 
immediaately subjacent to the pleura, this membrane may be 
penetrated with the production of pyo-pneumothorax. 

In unruptured abscess situated beneath the pleura that mem- 
brane is inflamed and covered with fibrinous or fibrino-purulent 
exudate. 

Physical Signs. — The physical signs of pulmonary abscess vary 
with the type which the suppuration assumes. Multiple small 



DISEASES OF THE LUNGS 165 

abscesses, distributed widely through the lung, and also a very 
diffuse purulent infiltration, give no distinctive physical signs. 
When the abscess is situated peripherally, just beneath the pleura, 
a friction fremitus and friction sound may be elicited in some 
instances, due to involvement of the pleura. 

When a large abscess has formed the signs are those of cavity, 
these signs coming and going as the cavity is empty or fills up. 
When the cavity is filled there is impairment of the vesicular 
resonance in the area of the abscess, absence of breath sounds, 
and abolition of vocal fremitus and resonance. When, on the 
contrary, the cavity is empty there is tympany in this region 
with the usual signs of cavity, cavernous or amphoric breath 
sounds and exaggerated vocal fremitus and resonance, with the 
phenomena of Wintrich, Friedreich, and Gerhardt. In pyemic 
cases the general condition of pyemia may mask the true condi- 
tion of the patient. 

When an abscess ruptures into a bronchus the diagnosis may 
be established by the expectoration of pus containing shreds of 
elastic tissue. The sputum is often copious, and change of pos- 
ture, by bringing the pus in contact with the healthy bronchial 
mucosa, may provoke an attack of cough with profuse expec- 
toration. 

The sputum in pulmonary abscess is often of rather offensive 
odor, but never has the stench of gangrene of the lung. The 
sputum contains shreds of elastic tissue and various pyogenic 
bacteria. In tuberculous abscess tubercle bacilli may occasionally 
be demonstrated in the expectoration. In abscess of long stand- 
ing the sputum contains crystals of cholesterin. 

Diagnosis. — Septic symptoms such as chill, fever, and colli- 
quative sweats, with copious expectoration of purulent sputum, 
and signs of cavity formation usually in a lower lobe of the lung, 
following upon one of the conditions which may be provocative 
of pulmonary abscess, suggest the diagnosis. In pyemic cases the 
multiple small abscesses are often obscured by the general symp- 
toms of pyemia. When a bronchus is penetrated and the copious 
expectoration containing elastic fibers occurs, the diagnosis is 
assured. When a patient with lobar pneumonia continues to 
have chills and fever after the crisis of the disease has passed, 
one should think of the possibility of a purulent infiltration super- 
vening upon the pneumonic state. 

Pulmonary abscess must be differentiated from broncliiectasis 
and empyema. 



166 PHYSICAL DIAGNOSIS 

Bronchiectasis often leads to the copious expectoration of puru- 
lent or muco-purulent sputum, but this sputum does not contain 
elastic fibers, and the history of the two diseases is entirely dif- 
ferent. 

Empyema may be accompanied by chills and sweats, but in this 
disease there is an extensive area of flatness posteriorly and ab- 
sence of breath sounds over this area. There is no copious expecto- 
ration with elastic fibers. 

From pulmonary gangrene, which also produces cavities, ab- 
scess is differentiated by the absence of the extreme fetor of the 
former, which pervades a house or hospital ward and suggests 
the diagnosis. 

GANGRENE OF THE LUNG 

Pathology. — Pulmonary gangrene is an occasional sequence 
of lobar pneumonia, more commonly of catarrhal pneumonia, in 
patients debilitated by alcoholism, diabetes, or w T ho suffer with 
chronic bronchitis. Gangrene of the lung may occur with pul- 
monary tuberculosis, pulmonary abscess, or tumor of the lung. 
Metastatic or embolic gangrene, following simple or infectious 
embolism is a common form of the disease. Gangrene of the 
lung may follow rupture into the lung of esophageal cancer, em- 
pyema, sub-phrenic abscess, or gastric ulcer. 

Injuries of the lung, as gunshot wounds, frequently result in 
gangrene. Injury due to foreign bodies in the bronchi may be 
provocative of the condition. Gangrene of the lung may start 
from the putrid contents of a bronchiectatic or tuberculous cavity 
in the lung. Occasionally during convalescence from a protracted 
illness gangrene of the lung develops without apparent cause. 

Pulmonary gangrene occurs in two forms, the diffuse, and the 
circumscribed forms. Of these, the diffuse is the rarer type of 
the disease. Diffuse gangrene of the lung occasionally follows 
pneumonia, but more commonly is the result of thrombosis of one 
of the large branches of the pulmonary artery. It is extensive, 
often involving the greater portion of a lobe of a lung. The 
affected area is dark in color, with a torn and ragged center, 
emitting an offensive odor. 

In the circumscribed form of gangrene there are multiple 
areas of gangrene which are always separated by undiseased 
areas of the lung. The condition usually affects one of the lower 
lobes, and is usually confined to the peripheral portion of the 
lung. In the early stage the gangrenous area is dark, but firm; 



DISEASES OF THE LUNGS 167 

Inter, softening occurs with the formation of a cavity which con- 
tains greenish, offensive fluid. Surrounding the gangrenous area 
is a /one of pulmonary tissue showing intense congestion, with 
splenization, and beyond this a /one of edematous pulmonary tis- 
sue. In rapidly spreading gangrene of the lung an artery may be 
eroded, leading to fatal hemorrhage. Perforation of the pleura 
is an infrequent complication, despite the peripheral distribution 
of the areas of gangrene. 

Bronchitis is a concomitant condition, owing to irritation of 
the bronchial mucous membrane by the fetid contents of the 
gangrenous cavities. Gangrene of the Lung is occasionally as- 
sociated with abscess of the brain. 

Physical Signs. — In a frank case of pulmonary gangrene with 
excavation of the lung the chief physical signs are those of 
cavity. When the gangrenous area is centrally situated, with 
healthy lung intervening between the site of disease and the 
chest Avail, physical signs are obscure or Lacking. There are pres- 
ent in nearly all cases characteristic signs of the coexisting bron- 
chitis. 

The breath is horribly fetid in pulmonary gangrene, this fact 
constituting a valuable sign of the disease when taken in con- 
junction with the sputum, which is characteristic. It is usually 
abundant, and upon standing separates into three strata: a 
lower of heavy greenish or brown sediment containing elastic 
fibers, granular material and pus. a median layer of brownish or 
greenish fluid, and a covering of grayish froth. Free blood may 
be present in considerable quantity; and hemoptysis may occur 
from erosion of an artery. 

Diagnosis. — The foul breath, associated with the characteristic 
sputum, with signs of cavity formation, hemoptysis and signs of 
general debility and prostration, render diagnosis easy. In cases 
of latent pulmonary gangrene the breath is often not foul, nor 
is the sputum characteristic, owing to the fact that the gangre- 
nous process is slow in progression and the area of gangrene is 
circumscribed by a fibrous wall. This form of the disease oc- 
curs particularly in diabetic and insane patients. In this class of 
patients an error in diagnosis is almost certain to arise. Mere 
foulness of the breath in any suspected case of pulmonary gan- 
grene does not make the diagnosis, as a foul breath may result 
from putrid bronchitis, decomposition of the contents of bron- 
chiectatic cavities, or carious teeth. 

In pulmonary abscess the sputum is abundant and purulent, but 



168 PHYSICAL DIAGNOSIS 

the breath is sweetish rather than foul, as in gangrene. Moreover, 
in the sputum of abscess shreds of elastic tissue are more abundant, 
and cholesterin crystals are more frequently encountered. 

Pulmonary tuberculosis with cavity formation sometimes pro- 
duces fetid breath and foul sputum containing elastic fibers; but 
the sputum in this disease contains tubercle bacilli, and the odor 
is never as foul as it is in pulmonary gangrene. Unfortunately, in 
gangrene acid-fast bacilli closely resembling in morphology the 
tubercle bacillus may be found in the sputum and lead to an error 
in diagnosis. 



CHAPTER XI 

DISEASES OF THE PLEURA 
ACUTE FIBRINOUS PLEURISY 

Pathology. — Acute fibrinous pleurisy, acute plastic pleurisy, 
or pleuritis sicca, is an acute in (lain mat ion of the pleura, which 
occurs in two forms, primary and secondary. 

Primary acute fibrinous pleurisy occurs as the result of expo- 
sure to cold, particularly in patients debilitated by the use of al- 
cohol or from other cause. Primary pleurisy lias also followed 
contusions of the thorax. 

Secondary acute fibrinous pleurisy is secondary to disease of 
the lung or to disease in more remote portions of the body. Tims, 
it follows or complicates many of the diseases of the hums, as 
bronchitis, tuberculosis of the lungs or bronchial glands, lobar 
pneumonia and broncho-pneumonia, bronchiectasis, infarction, 
abscess, or gangrene of the lung. Acute fibrinous pleurisy arises 
as a complication of the acute exanthematous fevers and occa- 
sionally during the course of other acute infections. 

Among primary lesions without the lungs which may be fol- 
lowed by acute fibrinous pleurisy may be mentioned endo-carditis, 
peri-carditis, tonsillitis, pyorrhea alveolaris, arthritis, and ty- 
phoid fever. 

The disease usually involves the lower lateral and anterior por- 
tions of the pleura, in which site it may be localized to a very 
small area, or may involve the greater of the pleura covering the 
lung. The pleura becomes dull and lusterless, with a rather gran- 
ular surface. The membrane is thicker than normal, and the 
surface is covered with one or more layers of fibrinous exudate. 
The exudate may be rolled into folds upon the surface of the 
pleura or may be thrown up into exuberant masses. There is a 
small amount of cloudy fluid exuding from the inflamed surface, 
but it never attains the degree which is seen in sero-fibrinous 
pleurisy or pleurisy with effusion. 

Microscopically the pleura presents desquamation and degen- 
eration of the covering endothelium in the seat of the inflamma- 

169 



170 PHYSICAL DIAGNOSIS 

tion, patches of the pleura being found entirely devoid of endo- 
thelial covering'. The sub-serous connective tissue layer is edema- 
tous and shows a variable degree of leukocytic infiltration. The 
blood vessels in the zone of the disease are congested. Upon 
microscopic examination of the exudate which is thrown out it 
is found to contain fibrin, serum, and pus cells. 

In very severe cases of long standing the visceral and parietal 
layers of the pleura often become adherent, crippling the move- 
ments of the lung to a variable extent during respiration. 

Physical Signs. — Inspection. — The expansion of the thorax on 
the side of the disease is limited, and the respirations are slightly 
quickened. Litten's phenomenon is abolished upon the side of the 
disease. 

Palpation yields the pathognomonic sign of acute fibrinous pleu- 
risy; namely, pleural friction fremitus, caused by the rubbing to- 
gether of the roughened surfaces of the visceral and parietal pleu- 
rae. If the site of the disease is in the portion of the visceral pleura 
in contact with the pericardium, there is pleuro-pericardial fric- 
tion fremitus. 

Palpation confirms minor deficiencies of expansion on the side of 
the disease. Vocal fremitus is usually unchanged ; but if there be 
considerable pleural thickening, its intensity is enfeebled over the 
area of the disease. 

Percussion. — The note elicited upon percussion over an area of 
acute fibrinous pleurisy is little changed in quality ; but percus- 
sion of the lower borders reveals limitation of the excursion of the 
diseased lung. 

Auscultation over the site of disease reveals the pathognomonic 
pleural friction rub ; and, in suitably placed lesions, pleuro-peri- 
cardial friction as well. The vesicular murmur is retained, but its 
intensity is slightly diminished. In great pleural thickening the 
murmur is abolished over the site of disease. Vocal resonance 
is as a rule unchanged ; but in the presence of considerable pleural 
thickening, its intensity is diminished. (See Fig. 67, p. 921.) 

Diagnosis. — The pleural friction when elicited is pathogno- 
monic. The disease also produces darting stabbing pain in the 
side, w T hich is increased by coughing and by deep inspiration, 
signs which also occur in other conditions. 

In pleurodynia there is pain in the side, but this pain is continu- 
ous and made worse by movements of the trunk and by those of 
respiration. There is absence of the friction sound, and the locali- 
zation of the pain is not as distinct as it is in pleurisy, the pain oc- 



DISEASES OF THE PLEURA 171 

casionally leaving one side and appearing upon the opposite side 
of the chest. There is no fever as there is with pleurisy. 

In intercostal neuralgia the pain is sharp and paroxysmal, ex- 
hibiting tender points over the exit of the nerves on the lateral and 
anterior chest walls. There is no friction sound and no fever. 

SEROFIBRINOUS PLEURISY (PLEURISY WITH 
EFFUSION) 

Pathology. — Sero-fibrinous pleurisy, or pleurisy with effusion 
may follow exposure to cold or a wetting, which permits bacteria 

present in the bodily economy to attack the pleura; but in certain 
cases exposure is the only apparenl cause of the disease. 

Lobar pneumonia by involving the pleura over a consolidated 
lobe often causes sero-fibrinous pleurisy; but there is sometimes 
seen a primary pleurisy with effusion caused by the pneumococ- 
cus and arising independently of disease of the lung. Pleurisy 
with effusion is an occasional complication of nephritis or rheu- 
matic fever, either due to the toxemia or to the bacteria asso- 
ciated with these disorders. 

The most common organism associated with sero-fibrinous 
pleurisy is the tubercle bacillus. In these cases the tuberculous 
focus may be situated in the lung or in a distant portion of the 
body. The streptococcus is the cause of certain cases of sero- 
fibrinous pleurisy, with or without the coincident development of 
a streptococcic broncho-pneumonia. 

In the female subject a sero-fibrinous pleurisy may be meta- 
static, resulting from tuberculous salpingitis. 

Pleurisy with effusion attacks males more frequently than 
females, usually attacking persons between twenty and fifty years 
of age, though no age is exempt. 

In sero-fibrinous pleurisy there is an initial dulling and loss of 
luster with roughening of the surface of the pleural membrane, 
but this is followed in a few hours by the exudation of a sero- 
fibrinous exudate. In a period varying from a few hours to sev- 
eral days there is more or less copious exudation of serous fluid 
from the surface of the inflamed pleura. 

The fluid gravitates to the dependent portions of the pleural 
sac, and mounts up higher and higher as the effusion develops. 
In some cases the effusion becomes so great that it reaches the 
clavicle. The lung, compressed by the increasing fluid, is crowded 



172 PHYSICAL DIAGNOSIS 

into the upper and posterior portions of the pleural cavity; occu- 
pying a comparatively small area near the spinal column. 

The exudate consists of a straw colored fluid having a specific 
gravity of approximately 1020, containing flocculi of fibrin, epi- 
thelial and pus cells, bacteria, and blood cells. "When the fluid is 
withdrawn spontaneous coagulation often is noted. The solid 
constituents of the exudate occupy the lower portion of the pleu- 
ral sac, and the fibrinous material adheres to the surface of the 
pleurae, where, often when the fluid is absorbed, it aids the for- 
mation of connective tissue adhesions between the visceral and 
parietal pleurae. 

These adhesions vary in extent in different cases. In some in- 
stances they are few in number and local; in other cases they are 
universally distributed over the entire pleura except for a pocket 
here and there ; while in yet other instances they may obliterate 
the pleural sac entirely, resulting in a chronic adhesive pleurisy. 
When a patient with these numerous adhesions has a second attack 
of pleurisy, it is apt to involve only the non-adherent portions of 
the membrane, resulting in loculated or sacculated pleurisy. 

In pleurisy with effusion the amount of the fluid in the pleural 
sac varies from one-half to four liters. After a variable course 
it tends to be spontaneously absorbed, often leaving after it the 
adhesions previously described. 

In cases where the amount of fluid in the pleural sac is exces- 
sive there is visceral displacement. The liver or spleen is dis- 
placed downward and the heart is displaced to the side opposite 
the effusion. 

Physical Signs. — Inspection. — The respiratory excursion on the 
side of the effusion is limited. If the effusion be large, there is 
uni-lateral bulging of the chest wall. Litten's sign is absent upon 
the side of the disease; the intercostal spaces are obliterated over 
the effusion or actually bulging. 

In effusions of the right pleural sac the cardiac impulse is dis- 
placed toward the left and sometimes is elevated to the fourth 
interspace, in some instances being visible in the left mid-clavic- 
ular line, or even in the left axillary region. In left sided effusion 
the impulse is displaced to the right, often occupying a position 
behind the sternum. In extreme cases it may be visible to the 
right of the sternum in the third or fourth interspace. 

The respirations are accelerated, oAving to compression of the 
lung by the effusion, with consequent diminution of the air space. 
There is visible scoliosis, the spine deviating toward the side of 



DISEASES OP THE PLEURA 173 

the effusion. The sound side of the thorax expands vicariously 
during respiration as a result of compensatory emphysema. 

The decubitus of the patient is sometimes of aid in diagnosis. 
During the early, dry stage of the disease the patient is apt to 
lie on the sound side in the effort to protect the sensitive pleura 
from pressure; while, after the effusion has developed, he usually 
lies upon the side of the effusion in order to facilitate the full 
expansion of the sound lung. The shoulder upon the side of 
the effusion is on a slightly higher level than is its fellow. The 
nipple and scapula on the side of the effusion are farther from 
the median line than on the opposite side of the thorax. 

Palpation. — In the first stage of the disease, prior to the de- 
velopment of the effusion, palpation reveals the presence in most 
cases of a pleural friction fremitus. If the lappet of lung over- 
lying the heart is involved, there is pleuro-pericardial friction 
fremitus. The friction fremitus is present during the dry stage 
of the disease; it usually disappears with the development of 
the effusion; and it reappears upon its absorption. But not in- 
frequently it can be detected during the effusion along its upper 
level, where the inflamed pleural membranes come in contact 
with the fluid. The friction fremitus not infrequently persists 
for years after recovery from the disease, as many patients can 
attest. 

Vocal fremitus varies according to the degree of the effusion. 
In the presence of moderate effusion, which does not fill the 
pleural sac, vocal fremitus is normal above the level of the effu- 
sion; while over the effusion it is abolished. Posteriorly, near 
the vertebral column, the area occupied by the compressed lung, 
vocal fremitus is apt to be exaggerated. In considering modifica- 
tions of the intensity of vocal fremitus, it must be borne in mind 
that dense pleural adhesions traversing a pleural effusion will 
and do transmit the vibrations to the palpating hand despite the 
presence of fluid in the pleural sac. 

Palpation of the precordia confirms displacements of the apex 
beat, and palpation of the lateral thoracic regions shows de- 
ficient expansion of the diseased side. There is seldom edema 
of the chest wall in sero-fibrinous effusion, this sign being more 
commonly present in purulent effusions. In effusion of the right 
pleural sac palpation reveals the lower border of the liver at an 
abnormally low situation. 

Mensuration. — Mensuration and comparison of the two sides of 
the thorax show an increase in the extent of the diseased side of 



174 PHYSICAL DIAGNOSIS 

from one-half to one and a half inches. Allowance must be made 
for the fact that the right side is normally larger than is the left. 

Percussion. — In the earliest stage of the disease the percussion 
note is unchanged. Later, as the effusion develops, there is a 
gradual impairment of the normal vesicular resonance, finally 
amounting to flatness over the effusion. Above the level of the 
effusion, the note is hyper-resonant, skodaic resonance. A similar 
hyper-resonant note is noted posteriorly above the level of the 
effusion. (See Figs. 55 and 56, p. 77.) 

With the patient in the upright posture Ellis's line of flatness, 
indicating the upper limit of the effusion, can occasionally be 
mapped out. In pleurisy with effusion this line, representing the 
upper limit of the effusion, is not horizontal. It is higher pos- 
teriorly than anteriorly. In effusions of moderate extent the line 
begins low down in the posterior region of the thorax and pro- 
ceeds upward and forward in a curve resembling the letter "S" 
to the axillary region, and thence proceeds in a gradual decline 
to the sternum. 

Grocco's triangle of para-vertebral dullness is demonstrable 
in most cases of pleurisy with effusion. This triangular area, 
with a width of two to five centimeters, with its apex directed 
upward, occupies the side opposite to the effusion. It is prob- 
ably due to displacement of the mediastinal structures by the 
pressure of the effusion. (See Fig. 52, p. 75.) 

In right sided effusion the dullness of the fluid blends an- 
teriorly and laterally with the dullness of the liver; whereas an 
effusion of the left side encroaches upon the tympany of Traube's 
semilunar space. 

In sero-fibrinous pleurisy it is rarely possible to detect mov- 
able dullness upon change of posture. While not always present 
in this disease, movable dullness when elicited is an infallible 
sign of fluid. 

Forcible percussion over the upper portion of the lung, above 
the level of the effusion, occasionally elicits a cracked-pot sound, 
produced by the sudden expulsion of air from the relaxed lung. 
Similarly, upon strong percussion over the infra-clavicular and 
mammary regions in very large effusions Williams's tracheal 
note may sometimes be elicited. 

During absorption of the effusion the dullness gradually is 
superseded by normal vesicular resonance, save at the bases 
posteriorly, where the resonance is apt to remain impaired for 



DISEASES OF THE PLEURA 175 

a Long period. Areas of impaired resonance elsewhere point to 
areas of pleural thickening or encysted fluid. 

Auscultation. In the early stage of the disease, prior to the 
development of the effusion, a friction rub is often audible upon 
auscultation. It is usually most audible in tbe lower axillary 
region. The rub usually but not invariably disappears when the 
effusion develops to become once more audible when resolution or 
absorption begins. A pleuro-pericardial friction rub can be beard 
when the portion of the pleura overlying the pericardium is in- 
volved. 

The breath sounds are abolished over the portion of the chest 
which overlies the effusion; while above the effusion the re- 
spiratory sounds are exaggerated or puerile. While the above 
statement as a rule is true, yet in very large effusions there is 
occasionally distant bronchial breath sounds audible over the 
effusion, due to the dense compression of the lung by the fluid 
which occupies the pleural cavity. The respiratory murmur 
over the sound lung is exaggerated or puerile owing to com- 
pensatory emphysema. 

Vocal resonance over the effusion is abolished, unless a patch 
of pleura be bound to the chest wall by adhesions, in which 
event the resonance is audible in the area in question. While 
vocal resonance is as a rule absent over the effusion, yet in some 
cases bronchophony is encountered in this area. Along the 
inner border of the scapula and along the vertebral column 
egophony is found in some eases. 

Baccelli's sign, the transmission of the Avhispered voice through 
a serous, but not through a purulent effusion serves to differ- 
entiate the former condition from the latter. 

Upon auscultation of the heart, the sounds are often rather 
diffusely audible, owing to cardiac displacement. The pulmonic 
second sound is usually found accentuated, and a systolic mur- 
mur may be audible, which is produced by traction upon the 
vessels by cardiac displacement. 

Diagnosis. — The diagnosis of sero-fibrinous pleurisy rests upon 
the deficient expansion and sometimes the bulging of the dis- 
eased side, the presence of the friction rub, which disappears 
with the advent of effusion, the absence of vocal fremitus over 
the effusion, the flat percussion note over the fluid, the absence 
of respiratory sounds over the effusion and puerile or bronchial 
sounds elicited above the level of the fluid, and presence of vis- 
ceral displacement, with certain special phenomena as bron- 



176 PHYSICAL DIAGNOSIS 

chophony, egophony and Baccelli's whispered voice in certain 
cases. The actual presence of fluid in the pleural cavity and its 
character are determined by aspiration. But aspiration may 
not in every case shoAv the presence of fluid. Even if the as- 
pirating needle is inserted in an area of flatness, it may pene- 
trate a region where a thickened pleura is adhered to the chest 
wall and so fail to secure fluid, though it is present. 

Pleurisy with effusion is often difficult to differentiate from 
lobar pneumonia. The points for differentiation between these 
diseases have been considered under lobar pneumonia (see page 
123.) 

From large pericardial effusion, sero-fibrinous pleurisy is some- 
times differentiated Avith difficulty, particularly in the cases of 
left sided pleural effusion. But in pericardial effusion the base 
of the lung yields resonance instead of flatness; there is skodaic 
resonance over the adjacent portion of the lung compressed by 
the effusion; the cardiac impulse is not displaced to the right; 
the heart sounds are feeble ; the pulse is the pulsus paradoxicus, 
trailing off toward full inspiration; and the degree of dyspnea 
is extreme, out of proportion to the extent of effusion. The area 
of dullness in pericardial effusion is pear-shaped with the base 
down. 

Uni-lateral hydrothorax presents physical signs which are 
identical with those of sero-fibrinous pleurisy. But in hydro- 
thorax there is absence of the initial friction rub; there is no 
primary pain in the side or fever; but instead a history of heart 
disease or nephritis. Hydrothorax is often accompanied by 
edema in other parts of the body. 

Ellis's curve is not present in hydrothorax and upon aspira- 
tion the fluid of hydrothorax is more serous, is of lower specific 
gravity, below 1.014; it contains less albumin than 3 per cent; 
and does not coagulate easily; and contains no bacteria. In 
hydrothorax movable dullness is easily obtained, as the fluid in 
hydrothorax readily shifts with change of posture, while in 
pleurisy with effusion this sign is obtained with difficulty if, 
indeed, at all. 

Intra-thoracic neoplasms may simulate pleurisy with effusion. 
They often produce displacements of the apex beat. The dullness, 
however, occupies the upper portions of the thorax and is of less 
extent, and is surrounded by a zone of compressed lung, yielding 
skodaic resonance. Vocal fremitus and resonance are increased 
rather than diminished. The breath sounds are often suppressed. 



DISEASES OF THE PLEURA 177 

The growths often produce and coexist with moderate pleural ef- 
fusion. Malignant neoplasms are prone to cause glandular enlarge- 
ment in the supra-clavicular fossag, and are eventually accompanied 
by cachexia. These growths also cause enlargement of the medias- 
tinal glands, producing thus pressure paralysis of the recurrent 
laryngeal nerves. The physical signs arc not influenced by change 
of posture. 

Hepatic enlargement from abscess, echinococcus cyst, or en- 
largement from sub-phrenic abscess may and do simulate pleurisy 
with effusion. But the upper limit of dullness "is immovable, 
with its convexity upward and a friction sound is audible over 
the dull area, which would not be the case if the pleural surfaces 
were separated by fluid." These conditions are often complicated 
by moderate pleural effusion and hence coexist therewith. Upon 
aspiration, the pus from a hepatic abscess shows liver cells and 
bile and perhaps amebae. Grocco's sign is absent. An echino- 
coccus cyst of the liver may produce hydatid fremitus. 

Pneumothorax produces uni-lateral bulging of the chest wall 
with immobilization; but the percussion note is hyper-resonant or 
tympanitic; and the disease presents certain characteristic signs, 
as the coin test, the metallic tinkle, and the succussion sound. 

LOCAL PLEURISY 

Under the head of local or circumscribed pleurisy several con- 
ditions or forms of pleurisy are embraced, as diaphragmatic 
pleurisy, loculated, sacculated, or encysted pleurisy, and inter- 
lobar pleurisy. 

Diaphragmatic Pleurisy 

In this form of pleurisy the inflammation is limited chiefly 
to the parietal pleura covering the upper surface of the dia- 
phragm and the visceral pleura in contact with it. 

The inflammation, as a rule, assumes the dry, plastic type; but 
there is sometimes moderate effusion, which may be serous or 
purulent. 

The Physical Signs are slight in comparison with the sub- 
jective symptoms, which are unusually severe in their manifesta- 
tions. There is urgent dyspnea ; the lower portion of the thorax 
is fixed, moving very little with respiration. A friction rub 
can sometimes be heard over the liver in right pleural disease, 
or over Traube's semilunar space in. left sided inflammation. 



178 PHYSICAL DIAGNOSIS 

There is tenderness upon pressure upon the lower intercostal 
spaces near the vertebral column, and extreme pain upon pres- 
sure over the insertion of the diaphragm at the tenth rib. There 
is often tenderness over the course of the phrenic nerve in the 
cervical region. Dysphagia is sometimes present, due to in- 
volvement of the esophageal orifice in the diaphragm; and hic- 
cough and vomiting accompanying left sided diaphragmatic 
pleurisy. The vomiting and respiratory movements exaggerate 
the pain. The diaphragm and abdominal muscles are fixed, and 
the respiration is costal. The fever is often high. The pain is 
most intense in the epigastric region, simulating in this respect 
acute disease of the abdominal viscera. 

The Diagnosis rests upon the very great severity of the sub- 
jective symptoms and the lack of physical signs. Gueneau de 
Mussy states that a pain extending from the tenth rib to the 
ensiform cartilage is pathognomonic of diaphragmatic pleurisy. 
Andral has noted cases attended with great dyspnea and attacks 
simulating angina pectoris. 

Loculated, Sacculated, or Encysted Pleurisy 

This type of pleurisy may be sero-fibrinous, but is more fre- 
quently purulent. In this form of pleurisy the fluid is circum- 
scribed by adhesions between the visceral and parietal pleura 
into one or more pockets or loculi, which may or may not com- 
municate with one another. While these loculi of effusion may 
develop in any portion of the pleural cavity, they are most fre- 
quently situated in the region between the mid-axillary line and 
the spine or upon the thoracic aspect of the diaphragm. In 
these cases the fluid may be bounded by adhesions, the result of 
a previous pleurisy; or an empyema may become limited and 
circumscribed by newly formed inflammatory adhesions. 

The Physical Signs are slight and confusing. Areas of dull- 
ness may be found in certain cases ; but this is not the rule ; and 
vocal fremitus may be clearly transmitted by the adhesions. 
The free use of the aspirating needle is the surest means of 
diagnosis. 

Inter-Lobar Pleurisy 

In the evolution of sero-fibrinous or purulent pleurisy the 
pleura clothing the inter-lobar fissures of the lung are also in- 
flamed, and often adhere, enclosing between the two pleural 



DISEASES OF THE PLEURA 179 

layers a variable amounl of sero-fibrinous or purulent effusion 

Also in cases of lobar pneumonia and pulmonary tuberculosis 
an inter-lobar inflammation of the pleura may occur, with co- 
hesion and retention of effusion. Inter-lobar pleurisy is usually 
purulent; and ofter simulates pulmonary abscess. Such a collec- 
tion of pus may perforate and discharge into a bronchus and 
lead to the expectoration of purulent sputum. 

Inter-lobar pleurisy usually develops near the root of the right 
lung, involving the pleura of the fissure between the upper and 
middle lobes of this lung. 

The Physical Signs of inter-lo'bar pleurisy are often very eon- 
fusing. As a rule there is little or no dullness upon percussion; 
but in certain cases a /one of dullness corresponding to the 
course of the fissure between the upper and middle lobes of the 
right lung can be found, Limited above and below by a zone of 
skodaic resonance. 

The x-ray is of aid in the diagnosis. Aspiration is dangerous, 
as the lung might be infected during withdrawal of the needle. 
The clinical picture often closely simulates thai of pulmonary 
abscess. 

PURULENT PLEURISY (EMPYEMA) 

Pathology. — Purulent pleurisy, or empyema occurs rarely as a 
primary disease, chiefly in young infants; but in the vast ma- 
jority of instances is secondary to disease or injury of the lung 
or thorax. 

Purulent pleurisy follows infectious diseases as scarlatina, lobar 
or lobular pneumonia, and pulmonary tuberculosis. It may be 
the result of abscess or gangrene of the lung. It may be caused 
by penetration or perforation of the chest wall by a fractured 
rib or other penetrating wound. Perforation of the diaphragm by 
sub-phrenic abscess may cause empyema. Carcinoma of the 
esophagus may penetrate the pleura and be an exciting cause of 
empyema. Finally, a. purulent pleurisy is a rare sequence of 
pertussis, measles, or typhoid fever. 

A purulent pleurisy is usually purulent from the outset, it 
being very rare for an effusion which is primarily serous to be- 
come secondarily purulent. Empyema is especially frequent in 
young children, although no age is exempt from the disease. 

The pneumococcus is responsible for the greater number of 
purulent pleurisies, either beginning as lobar pneumonia, or at- 
tacking the pleura primarily. Next in the order of their fre- 



180 PHYSICAL DIAGNOSIS 

quency, come the pyogenic cocci, the tubercle bacillus, B. in- 
fluenzae, and the colon bacillus. 

In purulent pleurisy the pleural cavity contains a variable 
amount of pus. The amount is usually quite large, often amount- 
ing to several liters. The solid constituents of the purulent fluid 
gravitate toward the dependent portions of the pleural sac, 
while the upper strata consist of fairly clear fluid. This fact may 
lead to an erroneous diagnosis; because, if the aspirating needle 
is entered above the level of the solid constituents, clear fluid may 
be withdrawn, suggesting the presence of a sero-fibrinous ef- 
fusion. 

The character of the pus varies in different cases. Usually it 
settles into two layers, thick below and clear above. In cases of 
considerable duration, it is thick and contains masses or shreds 
of fibrin. The pus may be odorless or fetid. 

As the ease progresses a greater or less degree of absorption 
of the exudate occurs. It is possible for the exudate to be en- 
tirely absorbed. Following absorption of the fluid elements, 
lime salts may be deposited in the remnants, imparting to them 
a gritty or calcareous quality. 

The pleura in the presence of the purulent effusion is con- 
gested and covered with layers of sticky fibrin, and remnants of 
degenerated endothelium. Eventually the surface of the pleura 
becomes covered with a gray pseudo-membrane, which when 
stripped off, leaves erosions, indicating areas of endothelial de- 
generation and desquamation. 

Pleural adhesions are frequently present in empyema. They 
are usually the result of a former pleurisy rather than of the 
empyema. They are mainly over the upper portions of the lung. 
This is probably because this portion of the pleuraa are in con- 
tact, while the portion lower down is separated by the fluid. The 
adhesions may be few, or they may extend well down to the sur- 
face of the fluid. 

There is organization and thickening of the pleural membrane, 
tending to prevent the transmission of the sounds arising within 
the lung. The visceral layer of pleura is more thickened than is 
the parietal. 

Changes in the Lung. — The empyema occupies space in the 
pleural sac previously occupied by the lung, so that this organ is 
compressed, and its expansion interfered with. This tends to 
produce a condition of atelectasis; and, in large effusions the 



DISEASES OF THE PLEURA 181 

tung occupies a very small space. The lung becomes solid, air- 
less, and of dark color. 

The heart is displaced by the effusion, and the impact of this 
organ against the fluid causes "pulsating empyema." The liver 
is displaced downward. 

Changes in the Thorax. — The collection of pus causes enlarge- 
ment of the affected side of the chest. The intercostal spaces 
bulge from the pressure exerted upon them. The diaphragm is 
pushed down and Avith it the liver and spleen. "After evacua- 
tion the affected side collapses, the shoulder droops, the inter- 
spaces retract, and there is spinal curvature toward the affected 
side." 

The pus of empyema may burrow beneath the costal pleura 
and point subcutaneously, constituting empyema necessitatis. 
Spontaneous evacuation of the pus will occur unless relieved. 

The pus may perforate the visceral pleura and discharge into 
a bronchus, causing pyo-pneumothorax. 

Physical Signs. — Inspection. — The physical signs of empyema 
on inspection are similar to those of pleurisy with effusion. But 
the diseased side bulges more than in sero-fibrinous pleurisy, and 
there is more extreme bulging of the intercostal spaces, particu- 
larly over the lower regions of the thorax. There is often edema 
of the chest Avail. The apex beat is displaced and the diaphragm 
is depressed by the weight of the purulent effusion, producing 
downward displacement of the liver or spleen. Tortuous dilated 
cutaneous veins are often visible over the lower chest. Litten's 
sign is absent on the side of the disease. The diseased side ex- 
hibits no respiratory movement. There is visible pulsation in pul- 
sating empyema, synchronous with the cardiac systole. In em- 
pyema necessitatis there is a protrusion of discolored integu- 
ment, indicating the point where rupture is imminent. 

Pal potion . — Vocal fremitus over the effusion is absent, perhaps 
exaggerated above the level of the pus. Pulsating empyema yields 
a palpable systolic pulsation. 

Percussion. — There is dullness amounting to flatness over the 
purulent effusion, and skodaic resonance above the fluid, as in 
pleurisy with effusion. 

Grocco's triangular area of para- vertebral dullness is usually 
well marked. 

Auscultation. — The whispered voice is often transmitted through 
a purulent effusion (Baccelli's sign). In children there is often 
blowing bronchial breathing above the level of the effusion. 



182 PHYSICAL DIAGNOSIS 

Diagnosis. — Purulent pleurisy closely resembles a sero-fibrin- 
ous pleural effusion in the external manifestations. But in em- 
pyema the disproportion between the two sides of the chest is 
more marked ; there is greater degree of intercostal bulging ; and 
the visceral displacement is more extreme. Edema of the chest 
Avail points to purulent rather than to serous or sero-fibrinous 
effusion. In empyema the dyspnea is greater, often amounting 
to orthopnea. There is less pain in empyema and there are signs 
of a septic state. Aspiration shows the presence of purulent ef- 
fusion. Baccelli's sign is often of aid in differentiation from 
serous or sero-fibrinous effusion. 

CHRONIC ADHESIVE PLEURISY 

Pathology. — Chronic adhesive pleurisy, chronic plas- 
tic, or fibrinous pleurisy, usually is a result of sero-fibrinous ef- 
fusion, more rarely of purulent pleurisy, and in rare instances 
develops as a primary or primitive affection. 

When a pleurisy with effusion is absorbed or aspirated, the sur- 
face of the pleura is covered with an exudate rich in fibrin factors 
and frequently there are areas in which the surface endothelium 
has desquamated, exposing the subjacent connective tissue basis, 
of the pleural membrane. The surface of the visceral and pa- 
rietal pleurge, coated as they are with fibrinous exudate, have a 
tendency to adhere to each other, and, the fibrinous exudate hav- 
ing undergone organization, the two surfaces become bound to- 
gether by fibrous adhesions. Between these adhesions, which vary 
In extreme cases the surfaces may adhere throughout their en- 
In extreme cases the surface may adhere throughout their en- 
tire extent, obliterating the potential pleural cavity. 

Physical Signs. — The physical signs of chronic adhesive pleurisy 
vary with the duration of the disease and the extent of the ad- 
hesions, varying from moderate dyspnea to extreme embarrass- 
ment and thoracic deformity. 

Inspection. — In cases with moderate adhesions slight dyspnea may 
be the only sign, or even this may be absent. But in more exten- 
sive cases, with many adhesions between the lung and chest wall 
local retraction or absolute immobilization of the side of the thorax 
is visible. 

Palpation. — Pleural friction fremitus is demonstrable over sites 
of pleural roughening and thickening. Palpation may detect minor 
degrees of deficient expansion and retraction. Vocal fremitus is 



DISEASES OF THE PLEURA 183 

as a rule diminished by the thickened pleura, occasionally exag- 
gerated. 

Percussion. — The percussion may be but little altered in cases of 
moderate pleural involvement ; or the note may be strikingly dull 
and the resistance marked in cases with obliteration of the pleural 
cavity in large part or its entirety. The note over the sound lung 
is hyper-resonant. 

Auscultation. — The pathognomonic pleural friction sound is au- 
dible, and the rales of an associated chronic bronchitis are often 
in evidence. The vesicular murmur is enfeebled or lost over a large 
portion of the thorax. 

Diagnosis. — The diagnosis is made upon the presence of the 
pleural friction rub, the thoracic deformity and respiratory em- 
barrassment, with a history of a previous acute pleurisy. 

HEMOTHORAX 

Pathology. — Hemothorax, a collection of blood in the pleural 
cavity, may result from rupture of an aneurism of one of the 
large intra-thoracic blood vessels or from erosion of an inter- 
costal vessel in pleural disease; or it may occur as a result of 
trauma to the chest wall, as a perforating wound or perforation 
from a i'raet need rib. Gangrene of the lung may be responsible 
for the hemorrhage, or it may be a portion of a hemorrhagic 
diathesis. Rupture of an aneurism of the aorta usually produces 
hemothorax of the left pleura. 

The onset of hemothorax is usually very abrupt. If one of the 
large vessels is the source, it is often rapidly fatal. In other 
instances the bleeding may be slowly continuous or may cease 
spontaneously after a variable length of time. 

The amount of blood extravasated into the pleural sac is va- 
riable. If infection does not occur, following arrest of the 
hemorrhage complete absorption may occur; not, however, with- 
out leaving pleural adhesions. 

Physical Signs. — These are the signs of internal hemorrhage; 
namely, pallor, dyspnea, rapid weak pulse, and collapse. Super- 
imposed on these are signs of effusion in the pleural sac, and as- 
piration reveals the presence of sanguineous fluid. 

CHYLOTHORAX 

Pathology. — Chylothorax, the presence of chyle in the pleu- 
ral sac, is encountered in rare instances. The chyle may be de- 



184 PHYSICAL DIAGNOSIS 

rived from rupture of the thoracic duct or discharge by transu- 
dation from the lacteals. Thus, the thoracic duct may be rup- 
tured by trauma to the thorax; or the duct may be obstructed 
by the pressure of an intra-thoracic tumor. Again, a chylous 
ascites may discharge into the pleural cavity by way of the 
lymphatics. Finally, occlusion of the left subclavian vein, into 
which the thoracic duct empties, may cause chylothorax. 

Physical Signs. — The physical signs are those of pleural ef- 
fusion. The nature of the effusion is determined by aspiration. 

HYDROTHORAX 

Pathology. — Hydrothorax, the presence of serous fluid in the 
pleural sac, develops as the result of transudation from the blood 
vessels in stasis of the blood stream, whether due to valvular 
heart disease, or to tumor pressing upon the large veins which 
convey blood to the heart. Blood changes, such as anemia and 
cachexia, may cause hydrothorax. Nephritis and carcinoma are 
occasional causes. 

The Physical Signs are those of moderate fluid in the pleural 
sac. But no friction rub is present. Movable dullness is easily 
obtainable. The heart, liver and spleen may be displaced. Ef- 
fusion is usually to-lateral. In cases dependent upon regurgi- 
tant heart disease it is often uni-lateral, and usually affects the 
right side. The fluid is shown by aspiration. It is of low specific 
gravity, less than 1.014, contains little fibrin and albumin. 

PNEUMOTHORAX (PYO- OR HYDRO-PNEUMOTHORAX) 

Clinical Pathology. — Pneumothorax is an accumulation of air 
or gas in the pleural sac. 

Pneumothorax is caused by perforating wounds of the chest 
wall by missiles or end of a fractured rib, or rupture of an em- 
pyema necessitatis. 

Diseases of the lung which cause communication between the 
pleural sac and a bronchus will cause it, as for instance, following 
the rupture of a tuberculous cavity situated close under the 
pleura. 

The development of the bacillus aerogenes capsulatus in the 
pleural sac will give rise to a primary pneumothorax. Perfora- 
tion of the diaphragm by a sub-phrenic or hepatic abscess may be 
a cause. The commonest cause of the condition is the rupture 
of a tuberculous cavity. 



DISEASES OF THE PLEURA 185 

The pleural cavity contains air or gas, Avhich compresses the 
Lung, which becomes shrunken and carnified. The heart, liver 
or spleen may be displaced. The air-containing pleural sac may 
be closed, with no opening to the exterior, or "open" with a 
communication with a bronchus or externally through the chest 
wall. There is usually a smaller or greater amount of serous 
fluid (hydro-pneuniothorax), or of pus (pyopneumothorax) 
present in the dependent portion of the sac. The lung is com- 
pressed and small, and pushed upward and backward against the 
spinal column. The cardiac displacement is great, but its posi- 
tion is unchanged. 

Physical Signs. — Inspection. — There is dyspnea and the facial 
expression is anxious. 

The affected side of the chest bulges, and the intercostal spaces 
bulge. The apex beat of the heart is displaced. Expansion on the 
diseased side is absent, in marked contrast to the vicarious expan- 
sion of the sound side. The patient usually lies on the side of the 
pneumothorax in order to give the sound Lung free play. There 
may be orthopnea. Litten's sign is absent on the diseased side. 

Palpation. — Vocal fremitus is absent unless it is conducted to the 
chest wall by way of pleural adhesions. 

Percussion. — The percussion findings depend upon the degree of 
tension of the air and the amount of fluid present therewith. If 
there is considerable fluid, it will give a dull note, with a sharp 
change into tympany when the upper border of the fluid is passed. 
The area of pulmonary resonance is increased upward above the 
clavicle and downward as a rule over the area of splenic and liver 
dullness. The coin test may be elicited. Movable dullness is 
demonstrable if fluid is present. (See Fig. 60, p. 81.) 

Cases with bronchial communication will give a cracked-pot 
sound, and Wintrich's change of note. Percussion over the precor- 
dia may give tympany or resonance, owing to displacement of the 
heart to left or right. Also in cases with patent bronchial com- 
munication Biermer's phenomenon, an alteration in the pitch of the 
percussion sound with change in the patient's posture, may be 
elicited. The dullness of the liver or spleen extends lower than 
normally. Biermer's phenomenon is often demonstrable. 

Auscultation. — The respiratory sounds are diminished or absent 
over the pneumothorax. In some cases distant amphoric breath 
sounds may be audible. The voice sounds are ringing and am- 
phoric. Over the sound lung the breathing is puerile. The me- 
tallic tinkle, falling-drop sound, or gutta cadens is audible; also 



186 PHYSICAL DIAGNOSIS 

the succussion sound upon shaking the patient. The lung fistula 
sound may be audible in cases with patent bronchial communi- 
cation. The heart sounds are apt to have a hollow, echoing sound, 
due to the proximity of the air in the pleural sac. (See Fig. 57, 
p. 78.) 

Diagnosis. —The uni-lateral bulging, with suppressed or absent 
breath sounds, tympanitic percussion note, the falling-drop sound, 
and succussion sound, with cardiac and visceral displacements 
make a characteristic picture. 

The differential points between pneumothorax, pleural effusion, 
and hydrothorax, have been discussed in a previous section. (See 
page 176.) 



SECTION IV 

PHYSICAL EXAMINATION OP THE CIRCULATORY 

ORGANS 



CHAPTER XII 
CLINICAL ANATOMY 

The Heart. — The heart, the great muscular pump by which the 

blood is propelled through the vessels, is roughly conical in shape, 
presenting* for examination a base, three borders I right, left, 
and inferior), and an apex. The heart is situated rather obliquely 
in the middle mediastinum, with the base directed backward and 
toward the right side of the thorax, and the apex directed for- 
ward and toward the left side. The heart does not occupy the 
mid-point of the thoracic cavity: but projects farther to the left 
of the median line than to the right. Approximately one-third 
of the organ is found in the right half of the thoracic cavity, and 
two-thirds in the left half of this cavity. 

The heart is divided by a longitudinal septum and a horizontal 
septum into four cavities, the right and left auricles and right 
and left ventricles. The auricles and ventricles are connected by 
the right and left auriculo-ventricular valves. The left auricle 
and ventricle contain arterial blood, while the right auricle and 
ventricle contain venous blood. 

The left auriculo-ventricular. or nut nil valve, intervening be- 
tween the left auricle and left ventricle, consists of a ring and two 
segments or cusps, whose closure is limited by the chordae tendinea? 
and papillary muscles. The right auriculo-ventricular or tricuspid 
valve, comprises a ring and three cusps or segments, similarly 
limited and controlled by papillary muscles and chorda? tendinea?. 
Arising from the left ventricle is the aortic orifice, comprising a 
ring and three segments, the segments being devoid of chorda? 
or papillary muscles ; but the segments are reinforced near their 
center by a thin cartilaginous plate, the corpus aurantii. Opposite 
each segment the wall of the aorta has a small pouch or dilatation, 
the sinus or Valsalva, from two of which arise the coronary arte- 

187 



188 



PHYSICAL DIAGNOSIS 



ries for the nourishment of the myocardium. The pulmonary valve, 
intervening between the right ventricle and the pulmonary artery, 
has the same structure as the aortic valve. 

The cardiac wall consists of specialized involuntary muscle fibers, 
the cardiac muscle, or myocardium, consisting of several layers of 
muscle fibers, the fibers taking various directions. The myocardium 
is clothed internally by a serous membrane, the endocardium, which 
is reflected over the cardiac valves ; and is covered externally by a 
similar serous membrane, the epicardium, which constitutes the 
visceral portion of the pericardium. 




Fig. 



-Relations of chambers of unopened heart to anterior chest wall. 



Arteries and Veins. — Arising from the left ventricle is the 
aorta, the greatest artery of the body. The aorta passes upward 
and to the right behind the sternum to the upper border of the 
second right costal cartilage; thence backward and toward the 
left, arching over the root of the left lung, to reach the left 
side of the fourth dorsal vertebra, whence its course is downward 
along the left side of the vertebral column to enter the abdominal 
cavity through the aortic orifice of the diaphragm. 

The pulmonary artery, arising from the right ventricle, courses 



CLINICAL ANATOMY OF CIRCULATORY ORGANS 



189 



upward and backward to the inferior aspect of the aortic arch, 
where it divides into right and left branches which enter the roots 
of the corresponding lungs. [1 is about two inches in length, and 
is connected to the lower portion of the aortic arch by the ligamen- 
tuni arteriosum, representing the obliterated ductus arteriosus. 




!.i ANT. PAPILLARY 
MUSCLE 



Fig. 89. — Relations of opened heart to anterior chest wall. (.From Gray.) 



Opening into the left auricle are the four pulmonary veins, re- 
turning arterial blood from the lungs ; while emptying into the 
right auricle are the superior vena cava, returning venous blood 
from the upper portion of the general circulation, and the inferior 
vena cava, returning the venous blood from the abdominal cavity 
and lower extremities. (See Fig. 2, p. 19.) 

The Pericardium. — The pericardium is a fibrous sac, covered 
on its external and internal surfaces by a thin serous membrane, 
the internal serous covering being reflected over the surface of the 



190 



PHYSICAL DIAGNOSIS 



heart as the epicardium. The pericardium secretes a small 
amount of serous fluid, enabling the parietal and visceral layers of 
the pericardium to glide noiselessly over each other during the 
cardiac contractions. The pericardium, Avith the heart, is pear- 
shaped with the base directed downward. The base of the peri- 
cardial sac is moored to the central tendon of the diaphragm 
by a little areolar tissue. 

The pericardium and heart are separated by the diaphragm 
from the left lobe of the liver, and, on the extreme left, corre- 



Foramina 
Thebesii 



Tubercle 
of Lower, 




Bristle passed through 
right auriculoventricular opening. 



Fig. 90. — Interior of right auricle and ventricle. (From Gray.) 



sponding to the apex of the heart, from the stomach. Upon 
either side the pericardium is covered by the mediastinal pleura, 
and is overlapped laterally and to a great extent anteriorly by 
the lungs. But anteriorly in the area of the Incisura Cardiaca a 
small portion of the right ventricle comes into direct contact with 
the chest Avail at the inner extremities of the fifth and sixth costal 
cartilages. Superiorly the pericardium is continued upAvard for 
a short distance upon the great vessels Avhich leave the heart. 
Surface Topography of the Heart. — The lase of the heart, 



CLINICAL ANATOMY OP CIRCULATORY ORGANS 



191 



formed by the right and left auricles, corresponds to a line cross- 
ing the sternum obliquely from the lower border of the second left 
costal cartilage, about one-half inch to the left of its junction with 
the sternum to the upper border of the third right costal cartilage, 
approximately one inch beyond its sternal junction. 




Fig. 91. — Interior of right auricle and both ventricles, showing mechanism of cardiac 

valves. (From Gray.) 



The right border of the heart, formed by the right auricle, cor- 
responds to a curved line, with its convexity directed to the right. 
extending from the upper border of the third right costal cartilage 
approximately one inch from its junction of the sternum, to the 
sixth right costo-sternal articulation. (See Fig. 89, p. 189.) 

The inferior border of the heart, formed almost entirely by the 
right ventricle, and to a small extent by the left ventricle, cor- 
responds to a line drawn, from the sixth right costo-sternal articu- 



192 



PHYSICAL DIAGNOSIS 



lation to the position of the normal cardiac impulse in the fifth 
left interspace one-half inch internal to the mid-clavicular line. 

The left border of the heart, formed by the left ventricle, is rep- 
resented by a curved line drawn with its convexity toward the left, 
from the fifth left interspace one-half inch internal to the mid- 
clavicular line to the lower border of the second left costal cartilage, 
one-half inch to the left of its articulation with the sternum. 

The cardiac valves all lie within a small ellipse extending from the 
third left costo-sternal articulation to the junction of the sixth 
right costal cartilage with the sternum. This area covers the ana- 
tomical site of the valves, but is not the area in which their 
sounds are best appreciated acoustically. 



RIGHT AURICULO- 
UTRICULAR ORIFICE 



PULMONARY 
ORIFICE 




LEFT AURICUtO- 
VENTRICULAR ORIFICE 



Fig. 92. — Fibrous rings at bases of cardiac valves. (From Gray.) 



The Aorta. — The ascending portion of the aorta is represented 
by a broad line drawn from the third left condro-sternal articula- 
tion to the second right costo-sternal articulation; thence the ves- 
sel takes a course backward and to the left, the arch ending upon 
the left side of the body of the fourth dorsal vertebra. 

The pulmonary artery corresponds to a broad line drawn from 
the second left intercostal space to the upper border of the second 
left costal cartilage, the point of bifurcation of the artery into its 
two main branches. 

The Precordia. — The term precordia is applied to the region 
of the surface of the thorax which overlies the heart. The name 
does not refer simply to the limited region in which the heart 



CLINICAL ANATOMY OF CIRCULATORY ORGANS 193 

is directly apposed to the thoracic wall, but also to the region in 

which the anterior borders of the lungs intervene between the 
pericardium and heart and the thoracic parietes. The region em- 
braces the areas of cardial dullness and cardiac flatness, to be 
described in a subsequent section. The precordia presents sharp 
margins or lines of division or borders above and to the left, but 
on the right side, it is continuous v\ith the areas ol hepatic dull- 
ness and flatness. (See Fig. 100, p. 2.13.) 



CHAPTER XIII 

INSPECTION 

In the study of cardio-vascular disease inspection reveals un- 
due prominence or recession of the precordia, abnormal pulsa- 
tions in the neighborhood of the precordia, the position and char- 
acter of the cardiac impulse and the presence of the capillary 
pulse in Corrigan's disease. 

THE PRECORDIA 

Undue prominence of the precordia is noted in pericarditis 
with effusion, cardiac hypertrophy and dilatation in patients with 
thin chest walls and in children. Aneurism of the aortic arch 
produces bulging in the upper portion of the precordial region. 
Precordial prominence may arise from causes not connected with 
the circulatory organs, as a tumor of the chest wall, lung or 
pleura; a cold abscess of the sternum, or a small localized pleural 
effusion. 

Undue recession of the precordia is often the result of the 
traction of pericardial or pleural adhesions. A not infrequent 
cause of retraction in this region is fibrosis of the left lung in 
fibroid phthisis or chronic interstitial pneumonia. A similar re- 
cession of the lower region of the sternum is seen in the funnel- 
chest, sometimes as the result of occupation, in other instances 
occurring as a congenital defect. 

ABNORMAL AREAS OF PULSATION 

At the Base of the Heart. — A visible pulsation at the base of 
the heart over the manubrium sterni, accompanying and syn- 
chronous with the systoles of the ventricles is indicative of aneu- 
rism of the transverse portion of the aortic arch. As a rule, when 
a visible pulsation is present in this locality the aneurism has 
eroded the bone, and is accompanied by pain of a boring char- 
acter. 

To the Right of the Sternum. — A pulsation visible along the 
right margin of the sternum ranging from the second to the fifth 

194 



INSPECTION IN CARDIO-VASCULAR DISEASE 195 

interspace, is indicative of right auricular dilatation, fibroid re- 
traction of the right lung associated with cardiac displacement, 
or to cardiac displacement by left sided pleural effusion or pneu- 
mothorax. 

To the Left of the Sternum. — Visible pulsation along the left 
sternal margin from second to sixth interspaces is indicative of 
aneurism of the descending portion of the aortic arch, dilatation 
of the left auricle or ventricle, fibroid retraction of the left long, 
or displacement of the heart to the left by pressure of air or fluid 
in the right pleural sac. 

In Epi-sternal Notch. — Visible pulsation in the epi-sternal notch 
sometimes follows the ingestion of stimulants, and often as a 
normal phenomenon in elderly subjects. Pulsation in this region 
also accompanies aneurism of the arch of the aorta, and develops 
when the subclavian artery is exposed by fibroid retraction of 
the lung. A pulsation in this notch sometimes accompanies 
anemic states. 

Systolic Pulsation of the Liver. — A systolic pulsation of the 
liver is indicative of tricuspid regurgitation, and is usually ac- 
companied by edema of the lower extremities. Often the pul- 
sation is not visible, but is readily palpable upon bimanual 
palpation. A true pulsation of the liver occurring with regurgi- 
tant tricuspid lesion must be differentiated from the impulse 
which is frequently transmitted to the liver by an overacting 
right ventricle. 

Epigastric Pulsations. — A systolic pulsation of the epigastrium 
is sometimes noted in healthy persons without possessing un- 
toward significance. Moreover, a systolic epigastric pulsation 
may accompany the condition of Bathycardia an abnormal low 
position of the heart in the thoracic cavity. Pathologic short- 
ness of the sternum causes a pulsation in the epigastrium, sys- 
tolic in time. A systolic epigastric pulsation accompanies hyper- 
trophy of the right ventricle, and occurs also when the heart is 
displaced to the right so that the apex lies behind the sternum. 

A diastolic pulsation of the epigastrium accompanies states 
of anemia and neurasthenia and is noted in patients with 
chronic gastric indigestion. A diastolic pulsation in this re- 
gion accompanies a tumor of an abdominal organ overlying the 
aorta, the pulsation being transmitted to the tumor at each pul- 
sation of the vessel. A similar pulsation accompanies aneurism 
of the vessel. These pulsations are often not visible, but plainly 
palpable. 



196 PHYSICAL DIAGNOSIS 

Systolic Pulsation of the Jugular Veins.— A systolic pulsation 
in these vessels is indicative of tricuspid regurgitation, the blood 
at each systole of the right ventricle regurgitating into the right 
auricle and causing a pulsation in the great vessels emptying 
their contents into this chamber. A second cause of such a pul- 
sation is mitral regurgitation in the presence of an unclosed fora- 
men ovale, in which event the back flow is felt through this 
abnormal opening upon the blood content of the right auricle, 
thus offering an impediment to the free discharge of the blood 
returning into the right auricle. 

DIASTOLIC COLLAPSE OF THE JUGULAR VEINS 
(FRIEDREICH'S SIGN) 

A diastolic collapse of these vessels is indicative of chronic 
adhesive pericarditis. In this disease the traction of the medias- 
tino-pericardial adhesions draw the chest wall in during cardiac 
systole, the flexible thoracic parietes expanding during diastole, 
thus exerting a suction upon the blood in the great vessels at the 
base of the right auricle, aspirating the blood from these vessels 
and leading to their sudden collapse during diastole. 

The Venous Pulse. — The venous pulse, as recorded in the inter- 
nal or external jugular veins, may be encountered in either of 
two forms: (1) the negative venous pulse of health; and (2) the 
positive venous pulse of pathologic significance. 

Negative Venous Pulse. — The negative, auricular, or presystolic 
venous pulse is represented by a sequence of presystolic pulsa- 
tions, usually demonstrable in the external jugulars, and only 
rarely in the internal jugular veins. The negative venous pulse 
can only be demonstrated in thin patients. In this type of venous 
pulse the presystolic pulse wave is initiated by the systole of the 
right auricle, which, in addition to forcing the auricular con- 
tents onward through the right auriculo- ventricular valve, also 
causes, coincidently, an impulse which is transmitted or imparted 
to the blood column in the superior vena cava and innominate 
veins, resulting in a presystolic impulse which is visible or pal- 
pable over the external jugular vein, particularly on the right 
side. 

These veins, during late diastole or just prior to ventricular 
systole, the time which corresponds to auricular systole, are full, 
owing to the increased intra-auricular tension; whereas, during 
ventricular systole, corresponding to auricular diastole, the veins 



INSPECTION IN CARDIOVASCULAR DISEASE 197 

collapse, owing to Lowering of the intra-auricular tension, which 
promotes the unimpeded flow of 1)1 ood from the veins. 

Sphygmograms from the external jugular veins of the negative 
venous pulse show often but a single wave, which corresponds to 
the auricular systole. But there may be two or even three 
waves, the second wave occurring during ventricular systole and 
corresponding to the closure of the right aurieulo-ventricular 
valve; the third wave occurring during ventricular diastole, and 
corresponding to the closure of the pulmonary valve. 

In determining the time of the negative venous pulse the ex- 
aminer should palpate the jugular vein with the finger-tips of 
tjie left hand, while applying the tips of the fingers of the opposite 
hand to the opposite carotid artery or to the cardiac apex. This 
maneuver serves to distinguish the normal, negative venous pulse, 
which is presystolic, from a false venous pulse transmitted from 
the subjacent carotid artery, which is systolic. Moreover, if 
digital compression is applied to the vein near the middle of the 
neck, after it has been emptied by pressure applied from below 
upward to the point of constriction, in the case of the negative 
venous pulse the proximal portion of the vessel remains empty, 
while the distal portion, the portion beyond the point of com- 
pression, becomes overfilled and tortuous. Under these circum- 
stances in a false venous pulse the carotid pulsation is not trans- 
mitted to the lower, collapsed portion of the vein; but it is in- 
creased over the portion of the vein above the site of compression. 

Positive Venous Pulse. — The positive, ventricular, or systolic 
venous pulse is represented by a sequence of systolic pulsations of 
the internal jugular veins. This type of venous pulse is caused 
by direct regurgitation of blood into the right auricle from the 
ventricle during systole, as the result of incompetence of the 
tricuspid valve. Hence, it is a purely pathologic physical finding. 
Usually first demonstrable in the right jugular, owing to its 
closer proximity to the right auricle, the pulse eventually de- 
velops in the left jugular vein. In thoroughly competent jugu- 
lar veins the impulse is interrupted at the supra-bulbar valve. 
Under these circumstances the impulse is appreciable in the inter- 
sterno-mastoid fossa, just above the sterno-clavicular articula- 
tion. But, as a rule, the valve above the bulb is not entirely 
competent and permits the impulse to be transmitted upward into 
the veins of the neck. 

While the provocative lesion of the positive venous pulse is in 
the great majority of cases tricuspid insufficiency, such a pulse is 



198 



PHYSICAL DIAGNOSIS 



also produced in the rarer cases of mitral incompetence asso- 
ciated with patent foramen ovale. The positive venons pulse is 
usually accompanied by systolic pulsation of the liver. 

The Centripetal Venous Pulse. — A visible pulsation, the cen- 
tripetal, or penetrating venous pulse, is occasionally visible in the 
veins of the dorsum of the hand or foot or in the delicate mam- 
mary veins. This pulse is most frequently associated with aortic 
insufficiency or anemia, in which it represents an exaggeration 
of the capillary pulse of Quincke. 

ABNORMAL RETRACTION OF THE THORAX (BROAD- 
BENT'S SIGN) 

In chronic adhesive pericarditis, with each systole of the ven- 
tricles, traction is exerted upon adhesions extending between 
the pericardium and chest wall, producing a systolic retraction 
of the thorax, most noticeable posteriorly below the angle of the 




Fig. 93. — Site of normal cardiac impulse. 

left scapula in the 10th and 11th interspaces. There is not in- 
frequently a similar systolic retraction of the anterior chest 
wall. Aside from chronic adhesive pericarditis, systolic retrac- 
tion of a local area of the chest wall may arise from the trac- 
tion of pleural adhesions, or may be an accompaniment of ven- 
tricular hypertrophy. 



INSPECTION IN CARDIO-VASCULAR DISEASE 199 

THE CARDIAC IMPULSE 

With each systole of the ventricles there occurs a visible im- 
pulse upon the chest wall. This impulse, which overlies the apex 
of the heart, is usually visible ; and in the rare instances in 
which it is not, is readily palpable. In the normal adult sub- 
ject this impulse is located in the fifth left intercostal space one- 
half inch internal to the mid-clavicular line. In infants and 
young children the impulse occupies a higher level and is sit- 
uated further from the median line, being found in this class of 
subjects in the fourth interspace three-eighths of an inch ex- 
ternal to the mid-clavicular line. In the aged, on the contrary, 
the cardiac impulse is frequently very low, occupying the sixth 
or the seventh interspace. 

The impulse covers an area of approximately one inch, and its 
force varies with the general physical development of the indi- 
vidual and with the state of the myocardium. A determination 
correctly of the exact position of the impulse affords very ac- 
curate information as to the position of the heart in the thoracic 
cavity. 

The cardiac impulse should be studied with a view to the detec- 
tion of displacement from its normal situation, its extent, and its 
strength. 

Displacement of the Cardiac Impulse 

The cardiac impulse may be displaced by pressure exerted 
upon the heart by adjacent viscera of the thorax or abdomen, by 
pathologic alterations in the myocardium, or by the collection 
of fluid in the pericardial sac, the direction and degree of the 
displacement often yielding a clue to the cause of the displace- 
ment. 

Upward displacement of the cardiac impulse is indicative of 
cardiac atrophy and moderate pericardial effusion. The impulse 
is also displaced upward by increased sub-phrenic pressure oc- 
curring in diaphragmatic hernia, sub-phrenic abscess, ascites, 
large tumor of an abdominal organ, hepatic enlargement, and 
in peritonitis, and tympanites. 

Downward displacement of the impulse occurs as the result 
of the growth of an aortic aneurism or a mediastinal tumor 
pressing upon the heart, or the pressure exerted by the over- 
inflated anterior borders and upper portions of the lungs in 
hypertrophic emphysema. 



200 PHYSICAL DIAGNOSIS 

Displacement to the Left. — The cardiac impulse is displaced to 
the left by the action of an accumulation of fluid or gas in the 
right pleural sac. The impulse is displaced toward the left when 
pleuro-pericardial adhesions between the pericardium and left 
lung exert traction upon the heart. Fibroid retraction of the 
anterior borders of the left lung in fibroid phthisis cause left 
displacement of the impulse. (See Figs. 81 and 83, pp. 145 and 
147.) 

In left ventricular hypertrophy and dilatation the impulse is 
displaced to the left and downward. The pressure of a mediasti- 
nal tumor may cause a similar displacement. 

Hepatic enlargement or distention of the stomach causes dis- 
placement of the impulse upward and toward the left. A similar 
displacement occurs in the presence of moderate pericardial 
effusion. 

Displacement to the Right. — The cardiac impulse is displaced 
toward the right by the pressure of fluid or gas in the left pleural 
cavity, and is drawn to that side by the action of right pleuro- 
pericardial adhesions. Compensatory emphysema of the left 
lung when marked may push the impulse to the right. In right 
ventricular hypertrophy and dilatation of the heart the im- 
pulse is displaced toward the right, perhaps lying behind the 
sternum. A similar displacement is noted in the rare cases of 
congenital transposition of the thoracic viscera. (See Fig. 82, 
p. 146.) 

Abnormal Extent of the Cardiac Impulse 

Increased Extent. — The extent of the cardiac impulse is exag- 
gerated in emotional states, and following physical exertion or 
excitement. The extent of the impulse is increased in cardiac 
over-action accompanying acute fevers or disorders of cardiac 
innervation. The area of impulse is increased by a mediastinal 
tumor pushing the heart forward, in cardiac hypertrophy and 
dilatation, in which latter it is seen over a very wide area. An 
increased area of impulse occurs when fibrosis of the anterior 
border of the left lung exposes an increased extent of the cardiac 
wall to the thoracic parietes, and when the left lung is drawn 
aside by pleural adhesions. 

Decreased Extent. — In hypertrophic emphysema owing to the 
crowding of the anterior borders of the lungs between the heart 
and chest wall the area of impulse is decreased or abolished. In 
extreme grades of cardiac dilatation the impulse. is frequently 
decreased or invisible. In deep chested subjects there may be a 



INSPECTION IN CABDIO-VASCULAB DISEASE 201 

very slight impulse or it may be absent. An absence of impulse 
may in some instances be explained by the fact that the apex 
is situated behind a rib. 

Abnormal Strength of the Cardiac Impulse 

Increased Strength. — In cardiac hypertrophy, in addition to 
being more diffuse thai] normally, the cardiac impulse is of in- 
creased force. Displacements of the impulse are usually found 
with hypertrophy. During active physical exertion, and strong 
emotional excitement there is a temporary increase in the strength 
of the impulse. Following the ingestion of cardiac stimulants, 
during the course of the acute fevers, and during acute myocardi- 
tis, the impulse is abnormally strong. 

Decreased Strength of the cardiac impulse occurs when cardiac 
dilatation supervenes upon hypertrophy, in conditions of fatty 
change in the myocardium, and in cardiac atrophy. In the 
presence of edema or inflammation of the chest wall the strength 
of the cardiac impulse is diminished, and in pericardial effusion 
or hypertrophic emphysema it is weakened or abolished. In 
pericarditis with effusion the impulse will sometimes become 
visible when the patient bends forward, disappearing when the 
erect posture is resumed. 

CAPILLARY PULSATION (THE CAPILLARY PULSE) 

Systolic pulsation in the capillaries is sometimes a normal phe- 
nomenon, may be the result of temporary loss of vasomotor tone 
during anemia or febrile diseases; but it is a very valuable sign 
of Aortic Insufficiency or Corrigan's disease. There are several 
methods of demonstrating capillary pulsation. A good method 
is by blanching the finger nail by the exertion of slight pressure 
upon the tip of the nail when a systolic flushing and a diastolic 
blanching of the subungual tissues will be observed, the capillary 
pulse. Another method of demonstrating the phenomenon is 
by drawing the nail over the forehead producing a line, which 
is alternately red and blanched. A third method of detecting 
the capillary pulsation is by covering the lower lip by a glass 
slide and observing the systolic flushing and diastolic blanching 
of the lip compressed by the slide The capillary pulse is fre- 
quently accompanied by visible pulsations in the veins of the 
dorsum of the hand or foot. ( See page 198.) 



CHAPTER XIV 
PALPATION 

In the study of cardio-vascular disease palpation is employed 
to locate the cardiac impulse when not visible. In performing 
this maneuver the whole hand should be placed flat palm down 
on the thorax over the apical area, not the fingers only. In 
palpating the apex beat information may be gained as to in- 
crease or decrease in the area of impulse, exaggeration or en- 
feeblement of its force, its quality, whether slow and heaving, 
as in hypertrophy of the left ventricle, or quick and slapping, 
as in cardiac dilatation; or whether the apex beat is regular or 
irregular. Shock from closure of the valves may be appreciated 
and, finally, friction fremitus and thrills may be detected. Pal- 
pation is also employed in study of the pulse. Palpation also 
confirms the findings of inspection as to prominences or retrac- 
tions in the precordial region, and pulsations within or without 
the precordia. 

Valve Shock. — This is due to closure of the valves of the heart, 
and can be appreciated when the hand is applied flat over the 
valve area. It may be felt over the auriculo-ventricular valves, 
but more distinctly over the semilunar valves. In both in- 
stances it is more intense in persons with thin chest walls. In 
the aortic and pulmonic areas it is more intense in cardiac 
hypertrophy. 

The pulmonic shock is intensified by left sided valvular lesions 
and in obstruction to the pulmonary circulation, as occurs in 
cases of emphysema and cirrhosis of the lung, conditions which 
raise blood pressure in the pulmonary circulation. 

The aortic shock is intensified in arterio-sclerosis, nephritis, 
and other conditions associated with increased blood pressure in 
the greater circulation. 

The shock of the auriculo-ventricular valves is systolic; that 
of the semilunar valves is diastolic. 

Pericardial Friction Fremitus.— This is a tactile vibration due 
to the rubbing of the parietal and visceral layers of the peri- 
cardium, which have become roughened by inflammation in the 
development of acute fibrinous pericarditis or the early stage of 

202 



PALPATION IN CARDIOVASCULAR DISEASE 



203 



pericarditis with effusion. The fremitus in the latter disease 
is likely to disappear with the development of the effusion, 
though it is not uncommon for it to persist at the base. 

Pericardial friction fremitus does not extend beyond the pre- 
cordia and is usually accompanied by some pain, which is ag- 
gravated by pressure over the lower end of the sternum. 

Thrills. — Upon palpation of the precordia of a patient the sub- 
ject of valvular heart disease, aneurism, or certain pathologic 
conditions of the blood, a vibration of the chest wall is noted 
which is not dissimilar to the sensation conveved to the hand 




Fig. 94. — Sites of palpable thrills and pericardial friction fremitus. 

/, thrill at mitral valve; 2, thrill at tricuspid valve; 3, thrill at pulmonary valve; 4, thrill 

at aortic valve; 5, pericardial friction fremitus. 



when placed upon the throat of a purring cat. This vibration is 
termed a thrill. 

Thrills may be cardiac, vascular, or hemic; they may be pre- 
systolic, systolic, or diastolic. A cardiac thrill is produced by 
the same condition which is responsible for a murmur; namely, 
a narrowing of an orifice through which the blood stream is pro- 
jected into a wider chamber beyond. So long as normal blood 
flows through normal vessels and orifices, of normal caliber, no 
sound is generated; but when the lumen at one point is de- 
creased, the blood passing through this into the wider distal 
portion produces the so-called "fluid veins," the vibrations of 



204 PHYSICAL DIAGNOSIS 

which are conveyed to the surface of the precordia as a tactile 
vibration, the thrill. 

In feeling for a thrill the entire palm of the hand should be 
applied lightly to the precordia. Firm pressure may obliterate 
the thrill. 

In general, a thrill at the base of the heart indicates aneurism 
of the aortic arch, but it may also occur in aortic or pulmonic 
valve lesions, particularly stenotic lesions, and in exophthalmic 
goiter. 

A thrill at the apex of the heart, pre-systolic in time, is a very 
good sign of mitral stenosis. If systolic in time, it is a sign of 
mitral regurgitation. 

A thrill at the second right, costal cartilage indicates trouble 
with the aortic valve or aorta, usually aortic stenosis. It may 
be due to aortitis, or aneurism. This thrill is systolic. A dias- 
tolic thrill at this area would signify aortic regurgitation. 

A systolic thrill at the second left costal cartilage is indicatve 
of pulmonic stenosis, while a diastolic thrill at the same area 
indicates pulmonary regurgitation. 

A thrill may be elicited over the carotid artery in exophthalmic 
goiter, due to the enlarged thyroid compressing the artery and 
disturbing its lumen.. 

THE PULSE 

By the term pulse is understood the expansion and contraction 
or rather retraction of an artery following each systole of the 
ventricles. Usually the radial artery at the wrist is the site se- 
lected for studying the pulse on account of its readiness of ac- 
cess, but other arteries, as the temporal, carotid, or femoral will 
serve the purpose. The pulse may be studied by digital examina- 
tion, or by the sphygmograph. 

Technic of Taking the Pulse. — In studying the pulse the pa- 
tient should be in the sitting or recumbent posture with the arm 
extended and resting upon a table or supported by the left hand 
of the examiner. The physician, seated beside the patient, should 
place three fingers over the radial artery, the index finger being 
nearest the patient's hand. With the fingers in this position the 
examiner may roll the artery beneath them and can study the 
several factors which enter into the analysis of the pulse. 

It is well in conditions where there is no cause for hurry to" 
count the pulse for a full minute, as observed by the second hand 
of a watch. It can, however, be counted for 20 seconds and the 



PALPATION IN CARDIOVASCULAR DISEASE 



205 



result multiplied by three; or counted for thirty seconds and the 
result multiplied by two. 

In certain diseases the pulse becomes so rapid that it is im- 
possible to count the beats. Under such circumstances an ap- 
proximate estimate of the frequency of the heats may be made 
h\ endeavoring to count every other beat, or the examiner may 




Fig. 95. — A method of finger-tip palpation of the radial artery. (Warfield, after Gi 




Fig. 96. — Another method of finger-tip palpation of the radial artery. (Warfield, after 

Graves.) 



make dots with a pencil held in the unengaged hand and count 
the number of dots made during a minute. 

In certain conditions in which the radial pulse cannot be 
felt, as well as in cases where it is suspected that every systole 
of the ventricles does not produce a radial pulsation, the exam- 



206 



PHYSICAL DIAGNOSIS 



iner may arrive at a conclusion by auscultating the apical area 
and counting the systoles. 

The Sphygmographic Tracing. — A tracing of the normal pulse 
or a sphygmogram shows that the pulse wave consists of a sud- 
den upstroke, the anacrotic limb, and of a gradual decline, the 
cat acr otic limb. The last mentioned limb falls gradually to the 
base line and is interrupted by a distinct notch midway in its 
descent, the dicrotic notch, followed by an immediate second 
ascent to a variable extent, the dicrotic wave, which is followed 
by a second wave, the post-dicrotic wave on the descent to the 
base line. 

The significance of the two principal strokes of the tracing is 
understood, the anacrotic limb being produced by the injection 
of blood into the already distended arteries by the ventricular 




J}. Z>jeroyt< /Vote h 
C - D/e r-oiit kV* r e 

S-CaTaCroy'c A/m6. 

Fig. 97. — Normal sphygmogram. 

systole, and the catacrotic limb being produced by the recoil of 
the elastic arteries to their normal caliber. 

The cause of the dicrotic wave is uncertain. It occurs im- 
mediately following the closure of the aortic valves. It occurs 
in all pulse tracings, varying, however, in degree. In certain 
pathologic conditions, as the early stages of typhoid fever, it is 
so pronounced as to lead to the designation " dicrotic pulse.' ' 
The accepted explanation is that the dicrotic wave is due to the 
rebound of the distended aorta at the time of the closure of the 
semilunar valves. 

The second notch on the catacrotic limb and the undulatory 
oscillations of the fall are probably due to inertia of the instru- 
ment. 

Variations in the Sphygmogram. — The most frequent patho- 
logic variations in the sphygmogram are due to increase and 
decrease in the arterial tension respectively. 

Thus, in conditions of high arterial tension, after the anacrotic 



PALPATION IN CARDIO-VASCULAR DISEASE 207 

limb attains the maximum height, instead of receding immediately 
as in normal tension, the stroke is sustained, for a variable time, 
producing a "plateau," gradually falling to the base line. 

In states of low arterial tension, on the contrary, the tracing 
presents a vertical anacrotic limb, with a quick fall to the base 
line with a rather marked dicrotic wave. 

Changes in the Artery. — When the radial artery is palpated 
with the finger-tips, it will be observed that at each pulse wave 
the artery is changed from a flat, compressible tube into a cir- 
cular one, and that the vessel lengthens or straightens out. 

Analysis of the Pulse. — In analyzing the pulse the examiner 
should study the points noted below, variations in one or all of 
which possess diagnostic significance: 

1. The condition of the artery wall. 

2. Size of the artery. 

3. Rate. 

4. Rhythm. 

5. Tension. 

6. Volume. 

7. Force. 

8. Duration. 

9. Bi-lateral symmetry of the pulses. 

The Condition of the Artery Wall. — The wall of the normal 
radial artery in a person not advanced in age is soft and yield- 
ing, readily compressible, and cannot be distinguished from the 
surrounding tissues. Any departure from this elastic state is 
significant. In the aged and in arterio-selerosis due to alcoholism, 
syphilis, gout, or other cause, the artery becomes hard and its 
walls unyielding. The vessel may often be rolled between the 
fingers and the lower end of the radius and feels like a pipe 
stem. Or the artery may be beaded and tortuous, with palpable 
nodules due to plaques of atheromatous degeneration. The ar- 
tery may be merely stiff and compressed less readily than usual. 
This is normal in persons past middle age. 

The Size of the Artery. — Variations in the size of the radial 
artery have little significance. The artery may be congenitally 
larger or smaller than normal. Temporary variations in caliber 
are due to increase or decrease in the blood content and are de- 
pendent on the amount of blood expelled at each systole of the 
ventricle. 

The Rate of the Pulse. — The normal pulse rate in an adult male 



208 



PHYSICAL DIAGNOSIS 



is 70 to 75 beats per minute. The rate, however, is modified by 
many factors, as the age, sex, the size of the body, the position 
assumed by the patient, and the relations of the time of taking 
the pulse to the meals. Thus, at birth the pulse rate is 130 to 
140 beats per minute. During the first year of life it is 115 to 
130; at the seventh year it average 85 to 90; whereas in the 
aged it drops to 60 to 70 beats per minute. In women the pulse 
is usually more rapid than it is in male subjects. 




Pti. /ju S //ft 



Pt4.fsus /Daryus. 




p>c*/sus Ce/et-. 




7*1* /s us r* 'Jus. 

Fig. 98. — Sphygmograms of pathologic pulses. (After Da Costa.) 

The size of the body has a slight influence on the pulse rate, 
the rate being slower in large subjects than it is in small persons. 
The position of the patient influences the pulse rate, the pulse 
being more rapid when counted in the upright posture than when 
counted while the patient is recumbent. The pulse rate is 
quickened for an hour or two following a full meal. Exercise 
and mental or emotional excitement temporarily increase the 
pulse rate, not infrequently doubling the normal rate for the 



PALPATION IN CARDIOVASCULAR DISEASE 



209 



individual. Finally, the examiner should remember that the 
ingestion of many drugs influence the rate of the pulse and 
proper questions should be directed toward this point. 

T^ot/jus f r&(f nests. 




pcc/Jt 



/ rarui. 



Pu /su I bi^A^ninm 




pu/juj tr/fet*'""' 



1 



/«/okj &ur*iS. 




pu/sui mo// 14 




p^/sus tJ/erolieut . 
Fig. 99. — Sphygmograms of pathologic types of pulse. (After Da Costa.) 

Physiologically the rate of the pulse is influenced largely by 
the degree of peripheral resistance. If the peripheral resist- 
ance is high, the heart will contract more slowly: whereas if the 



210 PHYSICAL DIAGNOSIS 

peripheral resistance be decreased by relaxation of the arterioles, 
the heart will contract more rapidly. The rate is also influenced 
by the action of the vagus nerves, stimulation of these nerves 
slowing the heart, and depression permitting the heart to con- 
tract more rapidly. 

As previously mentioned, the pulse rate varies with the age, 
sex, size, and position of the patient. An abnormally slow pulse 
rate is termed bradycardia, while the opposite condition, a very 
rapid pulse rate is termed tachycardia. Bradycardia occurs dur- 
ing convalescence from typhoid fever, pneumonia, and the acute 
infectious fevers, in cerebral tumors and hemorrhage, and after 
injuries to the cervical portion of the spinal cord, and in all 
conditions producing continuous stimulation of the vagus cen- 
ters. The pulse rate is also decreased in aortic stenosis and in 
sclerosis of the coronary arteries and in general arterio-sclerosis, 
depressed fracture of the skull, and fibrous myocarditis. 

Tachycardia occurs during fevers and vagus neuritis, ex- 
ophthalmic goiter, during violent exercise and emotional states, 
as well as during failing compensation in valvular lesions of the 
heart. 

Rhythm. — In health the pulse beats are of equal force and the 
beats are separated by uniform intervals. It follows that an ir- 
regularity of the pulse may have reference either to the force or 
the time sequence of the beats. 

Arrhythmia is a deviation from the normal sequence of the 
beats without the omission of beats. It is observed in the course 
of acute fevers, valvular heart lesions, particularly mitral stenosis, 
digestive disturbances, following excessive indulgence in tobacco, 
in brain lesions, gout, myocardial degeneration, in which it may 
be the only sign, during mental excitement, and occasionally in 
elderly persons without pathologic significance. 

Intermission is the occasional omission of a pulse beat. The 
omission may occur at irregular intervals or the omission may fol- 
low a regular sequence, every third, or every fourth beat being 
omitted. Intermission may persist throughout life without sig- 
nificance; or it may be merely a transient phenomenon. It is 
usually attributable to nervous depression or excessive use of stimu- 
lants or tobacco. 

In analyzing a case of intermission it is important to determine 
whether the omission is due to an omission of ventricular systole, 
the pidsus deficiens; or whether due to a ventricular contraction 



PALPATION IN CARDIOVASCULAR DISEASE 211 

which is too feeble to produce a radial pulse, the pulsus inter- 
mittens. 

When omissions of the pulse beats follow a regular sequence ; 
when they are rhythmically irregular, it is termed an allorhythmic 
pulse. In this variety of intermission belong the pulsus bigt minus. 
where two beats occur in regular sequence, and are followed by 
an omission; and the pulsus trigeminus, in which three beats occur 
regularly to be followed by an omission of the pulse. 

A very frequent form of irregularity is represented by the 
pulsus intercidens, a pulse in which after several regular beats the 
last regular beat is quickly followed by a weak one. 

The paradoxical pulse is a pulse in which on completion of in- 
spiration the beats become small and more rapid, and may become 
imperceptible at the wrist. It occurs in pericarditis with effusion 
and chronic adhesive pericarditis. 

Irregularities in the force of the successive pulse beats is due to 
ventricular systoles which are not of equal force. This condition 
is seen in the pulsus alternans, a pulse of regular rhythm but in 
which the successive beats are irregular in force. 

Volume. — The volume or size of the pulse is dependent upon the 
amount of blood expelled during ventricular systole, the ability 
of the aortic valve to prevent regurgitation, and the state of the 
vasomotor s} T stem. Thus, cardiac hypertrophy combined with 
vasomotor depression, permits relaxation of the arteries with the 
production of a full bounding pulse, the pulsus magnus. On the 
other hand, a weak or dilated heart, expelling at each systole a 
small quantity of blood, combined with vaso-constriction produces 
a small thready pulse, the pulsus parvus. This pulse is observed 
in inanition, mitral stenosis and regurgitation, and in marked 
aortic stenosis, conditions in which the ventricle cannot eject a 
large amount of blood into the aorta. 

Force. — The force of the pulse depends upon the energy with 
which the ventricle contracts, and upon the elasticity of the ar- 
terial walls. If the ventricle is hypertrophied but the arterial 
walls have lost their elasticity, much of the heart's force in ex- 
pelling the blood is wasted or lost by the absence of the elastic re- 
coil of the arteries. In general, the force of the pulse is increased 
in conditions of cardiac hypertrophy and is decreased in conditions 
of cardiac debility. Moderate stimulation of the vagus nerve in- 
creases the pulse force by slowing the heart and increasing its 
energy; but if the stimulation is extreme, the heart beats are so 
few that the decreased blood content of the arterial svstem is not 



212 PHYSICAL DIAGNOSIS 

sufficient for the powerful ventricular systole to act upon and the 
force of the pulse is diminished. 

Tension. — The tension of the pulse depends upon the energy of 
the cardiac contractions and the degree of peripheral resistance 
offered to the blood stream. Thus, with a powerfully contracting 
heart and the peripheral resistance increased by angiospasm or 
arterio-sclerosis, the arterial tension is increased (hyper-tension). 
Hyper-tension occurs in all conditions of cardiac hypertrophy, ar- 
terio-sclerosis, nephritis, uremia, and apoplexy. On the contrary, 
when the output of blood from the ventricle is decreased by cardiac 
dilatation or valvular lesions, combined with vasomotor relaxation 
or decrease of the amount of circulating blood due to anemia, 
hemorrhage, or cachexia, the arterial tension is diminished (hypo- 
tension). 

In hyper-tension the hard pulse is designated the pulsus durus 
in contradistinction to the soft, yielding pulse of hypo-tension, the 
pulsus mollis. 

Often in the course of a continuous fever there is noted a pulse 
of low tension and rate, and full volume, in which there is a re- 
duplication, appreciable to the palpating fingers as a minor beat, 
superimposed upon the principal beat, the dicrotic pulse. It is 
to be attributed to excessive elasticity of the arteries combined with 
a more or less general relaxation of the smaller arterioles. With 
the arterial system in this state, when the blood enters the ar- 
teries from the ventricles they are unduly distended, and the 
contraction of the vessels upon the blood column causes the sec- 
ondary pulse wave. 

Duration. — The duration of the pulse depends upon the degree 
of peripheral resistance, the elasticity of the arteries and the dura- 
tion of ventricular systole. 

The duration is increased in the slow sluggish pulsus tardus, 
which is always associated with increased peripheral resistance, 
due to constriction of the small arterioles, such as occurs in arterio- 
sclerosis, renal disease, and angina pectoris. The sphygmographic 
tracing of such a pulse shows a gradual upstroke, a well sustained 
plateau and a gradual fall to the base line. This slow pulse, the 
pulsus tardus, is observed also in aortic stenosis, in which case it 
is to be ascribed to the rather prolonged systole of the left ven- 
tricle and in which case the arterial pressure is low. 

The duration of the pulse is diminished, producing a quick 
pulse, the pulsus celer, in conditions associated with diminished 
peripheral resistance, due to relaxation of the arterioles, such as 



PALPATION IN CARDIOVASCULAR DISEASE 



213 



occurs in febrile states. A form of the pulsus celer is the water 
hammer pulse, or Corrigan Pulse which is observed in aortic re- 
gurgitation. This is a rapid pulse characterized by a sudden full 
expansion of the artery, followed by a sudden collapse of the vessel. 
Bi-lateral Symmetry of the Pulse. — Normally the radial pulse 
is exactly alike at the two wrists both as to time and character. 
This bi-lateral symmetry of the pulses may, however, be disturbed, 




Fig. 100. — Areas of cardiac and hepatic dullness and flatness. 



even to the total absence of the pulse at one wrist. Aneurism of 
the ascending aorta, or innominate artery, may retard the right 
radial pulse, while aneurism of the subclavian, axillary, or brachial 
arteries may cause retardation on either side. 

Fracture of the bones of the arm or injuries producing cicatri- 
cial compression of the artery in the axilla or arm, as well as com- 
pression by tumors or enlarged glands will alter the character of 
the pulse at the wrist and cause asymmetry of the pulses. Pneu- 
mothorax or large pleural effusion by compressing the subclavian 
artery may cause a retardation or may alter the character of one 
radial pulse. 



CHAPTER XV 
PERCUSSION 

Percussion is employed in the study of the circulatory organs 
chiefly to determine the position of the heart, and to detect al- 
terations in its shape and size, as well as the presence of fluid in 
the pericardial sac. In the determinaton of the size, shape, and 
position of the heart, this information is gained by outlining the 
areas of cardiac dullness upon the surface of the thorax. 

Areas of Cardiac Dullness. — When the examiner percusses to- 
ward the heart from various points in its vicinity upon the^ sur- 
face of the thorax, two changes in the quality of the percussion 
note are observed. As the borders of the heart which are over- 
laid by the anterior borders of the lungs are reached, the normal 
vesicular resonance becomes impaired, and finally, when the 
portion of the heart which lies in direct apposition with the chest 
wall, uncovered by the lungs is reached, the note becomes flat. 
Thus, there are and may be defined upon the thoracic surface two 
areas of cardiac dullness, the one within the other. The inner, 
representing the area in which the heart is uncovered by the 
lungs is termed the area of absolute cardiac dullness or the area 
of cardiac flatness, whereas the outer area, representing the por- 
tions of the heart which are overlapped by the anterior pulmonary 
borders is termed the area of relative cardiac dullness. 

The area of absolute cardiac dullness, representing the small 
portion of the right ventricle which is directly apposed to the 
anterior thoracic wall corresponds to a roughly triangular area, 
bounded on the right by a vertical line drawn along the left border 
of the sternum from the level of the fourth costal cartilage to the 
upper border of the sixth costal cartilage, on the left by a line 
drawn downward with a slight inclination toward the left from 
the junction of the fourth left costal cartilage with the sternum 
to the fifth left interspace midway between the left para-sternal 
and left mid-clavicular lines, and inferiorly by a line connecting 
the lower extremities of these two lines. (See Fig. 100, p. 213.) 

The area of relative cardiac dullness, representing the portions 
of the heart overlaid by the anterior borders of the lungs, is 
bounded on the right by a vertical line drawn upon the chest wall 

214 



PERCUSSION IX CARDIO-VASCULAR DISEASE 215 

from the upper border of the third costal cartilage near its junc- 
tion with the sternum along the right sternal border to the upper 
border of the sixth costal cartilage, on the left by a slightly curved 
line having its convexity toward the left and upward, drawn from 
the third left chondro-sterual junction to the fifth intercostal space 
one-half inch internal to the mid-clavicular line, and inferiorly 
by a horizontal line connecting the lower extremities of these two 
lines, from the upper border of the sixth right costal cartilage to 
the fifth left interspace one-half inch internal to the mid-clavicular 
line. Thus these areas roughly represent a triangle within a tri- 
angle, the area of absolute cardiac dullness lying within the area 
of relative cardiac dullness, except inferiorly. where the boundaries 
are the same, and where the flatness blends with the flatness of 
the liver. Similarly the right border of the area of relative 
cardiac dullness joins the upper border of the area of hepatic 
dullness at almost a right angle, the angle of resonance in the 
fifth right interspace being termed Ebstein's cardio-hepatic angle. 

Technic of Cardiac Percussion. — The areas of relative and abso- 
lute cardiac dullness, representing the size, shape and position 
of the heart, may be outlined by ordinary mediate percussion, 
or by auscultatory percussion. (See Fig. 46, p. 68.) 

In mapping out these areas by mediate percussion, the exam- 
iner should begin to percuss from three directions in order to 
fix the upper and lateral boundaries of the region, employing 
both deep and superficial percussion. In fixing the right and 
left borders the examiner should percuss from the right and left 
axillary region upon either side in the third, fourth, and fifth 
interspaces toward the precordia. employing deep percussion, 
until impairment of the resonance indicates that the lateral bor- 
ders of the area of relative cardiac dullness has been reached. 
Having marked these points upon the thoracic surface, the exam- 
iner continues the percussion, substituting superficial percussion 
for the deep percussion heretofore employed, in order to avoid 
eliciting the resonance of the anterior borders of the lungs, until 
the note elicited changes to flatness, indicating that the lateral 
margins of the area of absolute cardiac dullness have been reached 
representing the portion of the heart or right ventricle which 
is in direct contact with the chest wall. Having marked these 
points upon the chest wall, the examiner beginning in the left 
infra-clavicular region, percusses downward along the interval 
between the left sternal and para-sternal lines, employing first 
deep percussion, and when the upper limit of the area of relative 



216 PHYSICAL DIAGNOSIS 

dullness has been reached and marked, continuing with super- 
ficial percussion, until the upper limit of the area of absolute 
cardiac dullness is attained, which is similarly marked upon the 
chest wall. By connecting the points marked out upon the chest 
wall, at which the first change in the percussion note was noted 
in each instance, the areas of relative and absolute cardiac dull- 
ness are graphically represented upon the surface of the thorax.- 
and inferences as to the state of the heart may be drawn therefrom. 
In outlining the areas of relative and absolute cardiac dull- 
ness by auscultatory percussion, the details of technic of w T hich 
have been discussed in a previous chapter (see page 68), the chest- 
piece of the stethoscope should be applied to the chest wall a little 
above and slightly internal to the cardiac impulse while the ex- 
aminer percusses toward the heart and marks the tonal changes 
as they are encountered. Auscultatory percussion is a very -re- 
liable method of outlining these areas, but for clinical practice 
mediate percussion is ordinarily sufficiently accurate. 

VARIATIONS IN THE AREAS OF CARDIAC DULLNESS 

General Increase. — A general increase in the area of cardiac 
dullness in all directions is indicative of cardiac hypertrophy 
and dilatation, pericarditis with effusion, or a tumor of the 
mediastinal structures which pushes the heart forward. (See Figs. 
101 and 102, p. 217.) 

General Decrease. — A decrease in all the borders of the area 
of cardiac dullness is indicative of cardiac atrophy, or pericardial 
adhesions drawing the heart under the anterior pulmonary bor- 
ders. Hypertrophic emphysema, by interposing the voluminous 
anterior borders of the lungs between the heart and chest wall 
causes a general decrease in the area. 

Displacement of the Area, as indicated by displacement of the 
apex beat occurs in pleurisy with effusion, traction of pleural ad- 
hesions, or sub-diaphragmatic pressure. The entire area of the 
cardiac dullness is displaced, but of normal dimensions. 

Upward Increase. — An increase of the area of cardiac dullness 
in an upward direction accompanies pericarditis with effusion, 
and in the presence of aneurism of the ascending portion or arch 
of the aorta. In pericarditis with effusion the area becomes ir- 
regularly pear-shaped with its base downward, owing to the char- 
acteristic configuration of the pericardial sac. 

Increase to Left.— An increase in the area of cardiac dullness 
toward the left occurs with hypertrophy and dilatation of the 



PERCUSSION IN CARDIO- VASCULAR DISEASE 



217 




Fig. 101.— Right and left ventricular hyper- Pig. L02. Urge pericardial effusion. (Ke- 
trophy. (Redrawn from Butler.) drawn from Butler.) 




Fig. 103.— Heart in left ventricular hyper- Fig. 104.— Right ventricular hypertrophy. 
trophy. (Redrawn from Butler.) (Redrawn from Butler j 




Fig. 105.— Areas of cardiac and vascular dullness. (Redrawn from Butler.) 



218 PHYSICAL DIAGNOSIS 

left ventricle, and in cardiac displacement by mediastinal pres- 
sure. In left ventricular hypertrophy the area is increased both 
to the left and downward. 

Increase to Right. — An extension of the area toward the right, 
the dullness of the heart encroaching upon the normal vesicu- 
lar resonance of Ebstein's cardio-hepatic angle, occurs with 
right ventricular and auricular hypertrophy and dilatation, and 
in pericarditis with effusion, in which disease it constitutes 
Botch's sign. A distended inferior vena cava may be responsible 
for a slight extension of the area of dullness to the right of the 
sternum. When the extension is the result of right ventricular 
hypertrophy there are often present epigastric pulsations, sys- 
tolic in time, while right auricular dilatation is often accompanied 
by systolic pulsations in the jugular veins. 

Vascular Dullness. — An area of dullness extending beyond the 
margins of the manubrium sterni, particularly if encountered 
upon the right side in the first or second interspaces, is usually 
a sign of aortic aneurism. 



CHAPTER XVI 
AUSCULTATION 

Auscultation is utilized in the study of the circulatory organs 
to determine the character and intensity of the heart sounds, their 
rhythm, and the presence or absence of certain adventitious 
sounds arising in the heart, pericardium, and arteries. 

The Normal Heart Sounds. — The heart in its action produces 
two sounds, which are termed the first and the second sound of 
the heart respectively. The first sound is heard most clearly as a 
rule in the region of the cardiac apex, while the second sound is 
most clearly audible at the base of the heart. 

The first sound of the heart is lower in pitch and of longer dura- 
tion than is the second sound. It has been compared to the sound 
of the word "lubb." It is most probably caused by the combined 
effect of the closure of the auriculo-ventricular valves, the contrac- 
tion of the cardiac muscle, and the vibrations of the chordae 
tendineae following coaptation of the valve segments. 

The second sound of the heart is of higher pitch and of shorter 
duration than is the first sound, being closely simulated by the 
sound of the word "dup." The second cardiac sound is un- 
questionably produced by the closure of the semilunar valves 
guarding the orifices of the aorta and pulmonary artery. The 
first sound of the heart is audible during cardiac systole, and is 
hence termed systolic; whereas the second sound occurs during 
diastole, and is termed diastolic. In health these two cardiac 
sounds follow each other in regular sequence or rhythm and are 
followed by a slight pause. 

The cardiac contractions occur approximately 72 times per 
minute in the healthy adult male subject. However the rate of 
contraction is influenced by sex and age. In the female subject 
the rate is often somewhat higher than it is in the male. Age 
is attended by more definite and distinct variations in the heart 
rate. Thus at birth the rate is 130 to 140 contractions per min- 
ute, diminishing to 90 to 100 at the fifth year of life; while in the 
aged the rate is 60 to 72 per minute. 

Auscultatory Valve Areas. — Each of the four valves of the 
heart has a corresponding area at which the sound produced by 

219 



220 



PHYSICAL DIAGNOSIS 



the closure of the valve in question is more distinctly audible 
than elsewhere upon the surface of the chest. These areas do 
not correspond to the point of the thoracic wall which is nearest 
to the anatomic site of the valve. Thus, the mitral valve is most 
clearly audible over the mitral area which is situated over the 
apex of the heart, although the anatomical site of this valve is be- 
hind the left half of the sternum at the level of the fourth costal 
cartilage. 

The aortic valve is best examined at the aortic area, just to 
the right of the right sternal border in the second intercostal 
space, although the anatomical site of this valve is posterior to 




106. — Auscultatory valve areas. 



J, mitral area; 2, tricuspid area; 3, pulmonary area; 
4, aortic area. 



the left half of the sternum at the level of the third interspace. 

The tricuspid area, at which sounds arising from the tricuspid 
valve are most distinctly audible, is situated over the lower end 
of the sternum, the anatomical site of this valve being behind the 
right portion of the sternum between the level of the fourth and 
sixth costal cartilages. 

The pulmonary area, at which sounds generated by the action 
of the pulmonic valve are best appreciated occupies a point just to 
the left of the left sternal border in the second intercostal space, 
the anatomical site of this valve being posterior to the junction of 
the third left costal cartilage with the sternum. 



AUSCULTATION IN CARDIOVASCULAR DISEASE 221 

Upon examination of the cardiac sounds of a normal subject it 
will be noted that the individual sounds arising at the different 
valve areas of the heart are not of uniform intensity. Thus, al- 
though the first sound of the heart is produced by the combined 
action of the two auriculo-ventricular valves, it will be observed 
that the first sound at the mitral area is lower in pitch and of 
somewhat greater duration than is the tricuspid first sound. 
Similarly, in examining the component valves concerned in the 
production of the second sound, it will be observed that in an 
adult subject the second sound at the aortic area is of greater 
intensity and duration than is the same sound generated by the 
pulmonary valve; whereas in a child the condition is reversed, 
the pulmonary sound being more intense than is the aortic sec- 
ond sound. 



VARIATIONS IN INTENSITY OF THE CARDIAC SOUNDS 

The intensity of the cardiac sounds as elicited at the various 
valve areas vary in intensity in different morbid states having 
their inception in the heart or in distant portions of the body. 
The intensity of both sounds or of one sound may be increased or 
diminished at one or more valve areas. 

Accentuation of Both Sounds. — Both sounds of the heart are 
accentuated in the presence of cardiac hypertrophy, in cardiac 
over-action during exophthalmic goiter, acute febrile diseases, 
following the ingestion of cardiac stimulants, and as a result of 
violent plrysical effort. An apparent accentuation of both 
sounds is sometimes encountered in subjects with very thin chest 
Avails, and also in patients in whom fibroid retraction of the an- 
terior border of the left lung exposes the heart to the chest 
wall. A consolidation of the lappet of lung overlying the heart 
transmits the normal cardiac sounds to the surface of the thorax 
with exaggerated intensity, simulating a true accentuation of the 
tones. 

Diminished Intensity of Both Sounds. — In robust patients with 
thick chest walls, in the presence of pericarditis with effusion, 
when a certain amount of fluid intervenes between the heart and 
chest wall, and in hypertrophic emphysema when the distended 
anterior borders of the lungs intervene between the heart and 
thoracic wall, the cardiac sounds are weakened, without pos- 
sessing any reference to the state of the myocardium. In car- 



222 PHYSICAL DIAGNOSIS 

diac dilatation, and myocardial degeneration the sounds are 
weakened from impairment of the integrity of the myocardinm. 



A B 

Fig. 107. — A. Normal first and second sounds. B. Accentuated first sound. 

General asthenia from long continued wasting disease causes 
a weakening of both cardiac sounds. 

Accentuation of the First Sound. — An abnormal intensity of 
the first sound at the mitral area, of slightly increased duration, 
followed by an abnormally intense aortic second sound is in- 
dicative of left ventricular hypertrophy. When dilatation is 



A B 

Fig. 108. — A. Normal first and second sounds. B. Diminished first sound. 

about to supervene, the first sound as elicited at the apex is loud 
but of brief duration and has engrafted upon it the valvular 
quality of the normal second sound. 

Diminished Intensity of the First Sound. — Weakening and 
degeneration of the myocardium of the ventricle which accom- 
panies cardiac dilatation, the asthenia of chronic wasting dis- 
ease, anemia, and prolonged fevers leads to a diminution in the 



A B 

Fig. 109. — A. Normal first and second sounds. B. Accentuated second sound. 

intensity of the first sound at the apex, the sound taking on a 
valvular quality analogous to that of the normal second sound. 
Accentuation of the Aortic Sound. — The aortic sound is ac- 
centuated in all states of the body which are accompanied by an 



AUSCULTATION IN CARDIOVASCULAR DISEASE 223 

increased tension in the greater circulation. Hence it is en- 
countered in cases of angiospasm due to vaso-constriction, in 
arterio-sclerosis, chronic interstitial nephritis, uremia, and apo- 
plexy. When the root of the aorta and the semilunar valves par- 
ticipate in general arterio-sclerosis, the aortic sound is accen- 
tuated, with a metallic, clinking quality. In hypertrophy of the 
left ventricle the aortic second sound is accentuated, to become 
weakened with the inception of dilatation. 

Diminished Intensity of the Aortic Sound. — Weakening in the 
aortic sound accompanies lowering of the blood pressure in the 
greater circulation incident to hemorrhage, anemia, relaxation 
of the peripheral arterioles, and when, as a result of mitral or 
aortic stenosis or insufficiency, a diminished quantity of blood is 
ejected into the aorta during ventricular systole. Naturally the 
aortic sound is impaired or weakened in conditions which impair 
the integrity of the myocardium of the left ventricle as in car- 
diac dilatation and myocardial degeneration. 

Accentuation of the Pulmonic Sound.- Conditions which raise 
the blood pressure in the pulmonary circulation, as in the case of 
obstructive pulmonary disease such as cirrhosis of the lung, 
pneumonia, phthisis, and emphysema, produce accentuation of 
the second sound at the pulmonary area. Similarly, regurgi- 
tant and stenotic lesions at the mitral or aortic valve, by per- 
mitting the blood to accumulate in the pulmonary circuit and 
thus raising blood pressure here lead to a similar accentuation. 
Tumors or enlarged glands pressing upon the great veins re- 
turning the blood from the lungs to the right heart operate in the 
same manner. In right ventricular hypertrophy from any cause 
the second sound at the pulmonary area is accentuated. 

Diminished Intensity of the Pulmonic Sound. — Weakening or 
failure of the pulmonic second sound is indicative of failure of 
the right side of the heart. When a pulmonic sound which has 
been accentuated becomes weak, it indicates right ventricular 
dilatation or the development of tricuspid regurgitation. 

Reduplication of the Heart Sounds. — Either or both sounds 
of the heart may under certain circumstances become doubled or 
reduplicated. Ordinarily the examiner encounters a reduplica- 
tion of either the first or second sound, rarely of both. If the 
first sound is reduplicated the sound resembles the Avords "lur- 
rup-dup," whereas if the second sound is reduplicated alone, 
the sound resembles the spoken words ''lub-durrup." In cer- 
tain instances these sounds are so accented as to resemble the 



224 



PHYSICAL DIAGNOSIS 



gallop of a horse, under which circumstances the sound has 
been termed "gallop-rhythm" or "canter-rhythm," or the 
"bruit de galop." 

Reduplication of the first sound of the heart is only rarely en- 
countered, and the mechanism of its production is beset with 
difficulties. It has been asserted that the reduplication is due to 
a-synchronous closure of the mitral and tricuspid valves, owing 
to a-synchronous systole of the right and left ventricles. The 
phenomenon has also been referred to unequal tension of the 

M 



A B 

Fig. 110. — A. Normal first and second sounds. B. Reduplicated first sound. 



Fig. 111. 



Normal first and second sounds, 
second sound. 



B. Reduplicated and accentuated 



leaflets of the two auriculo-ventricular valves. The sound pro- 
duced by reduplication of the first sound of the heart is often 
confused with a pre-systolic mitral murmur which is followed by 
a normal first sound. Reduplication of the first sound may be a 
sign of mitral stenosis, or it may develop on account of lesions 
of the auriculo-ventricular valves during failure of compen- 
sation. 

Reduplication of the second sound of the heart is to be attrib- 
uted to a-synchronous closure of the aortic and pulmonary valves 
as a result of unequal tension in the greater and lesser circula- 
tions. Hence, a reduplication of the sound is noted in all states 
which raise the pulmonary blood pressure, as in emphysema, cir- 
rhosis of the lung, pneumonia, and left sided valvular heart 
disease; and in association with arterio-sclerosis and chronic in- 
terstitial nephritis, raising the pressure in the general circulation. 
Reduplication of the second sound has been noted in normal sub- 
jects during deep inspiration. 



AUSCULTATION IN CARDIO-VASCULAR DISEASE 225 

CARDIAC ARRHYTHMIA 

Clinical Attributes of the Myocardium. — For a proper appre- 
ciation of the subject of cardiac arrhythmia certain inherent 
properties or clinical attributes of cardiac muscle per se must 
be considered. These properties or attributes comprise rhyth- 
micity, tonicity, irritability, conductivity ana* automaticity. 
It must also be borne in mind that the cardiac contractions are 
always maximal, regardless of the strength of the stimulus 
which calls the contraction into being. 

Throughout life the heart continues a scries of rhythmical con- 
tractions, in health ventricular systole and diastole following 
similar phenomena in the auricles in regular and undisturbed 
rhythm. This rhythmicity involves both the strength and the 
time of the contractions. This scries of contractions and relaxa- 
tions, separated by definite and regular periods of repose con- 
stitute the cardiac cycle. Assuming that the regular series of 
events occurs 72 times per minute the time occupied by each of 
the elements of the cycle may be taken to be as follows: The 
entire cycle consumes 0.8 of a second. The contraction of the 
auricles consumes 0.1 of a second: the contraction of the ven- 
tricles, 0.3 of a second; and the period of repose of the entire 
heart 0.4 of a second. 

The heart constantly remains in a state of partial contraction, 
constituting the tone of the organ. Possessed by all portions of 
the myocardium the widest variations in tonicity are encountered 
in the auricles, in which Botazzi has demonstrated that the varia- 
tions of tone are periodic and wave-like. 

The myocardium possesses an inherent irritability to stimuli 
reaching it from without, the degree of irritability varying in 
different portions of the organ. The irritability is markedly 
influenced by the state of nutrition of the cardiac walls. Un- 
like muscle from other organs or portions of the body, the 
strength of the response of the myocardium to a stimulus which is 
applied bears no definite relation to the degree of stimulation; 
but the response is maximal to all stimuli, strong or weak. More- 
over, after a response has been excited by a stimulus reaching the 
heart, there is no response to a second stimulus reaching it after 
the initial response is started until its completion, the so-called 
Refractory Period. If, however, a contraction be excited earlier 
than it would automatically occur, the succeeding pause before 



226 PHYSICAL DIAGNOSIS 

the next regular contraction is longer, constituting the so-called 
Compensatory Pause, a very important point for consideration in 
the study of arrhythmia of the extra-systolic type. 

The myocardium possesses the property of conducting an im- 
pulse arising in the auricles to the ventricles by means of a 
specialized muscular bundle, the auriculo-ventricular bundle of 
His. The specialized fibers constituting this conducting bundle 
arise in the wall of the right auricle and interauricular septum, 
whence branches are sent upward as far as the great veins. The 
bundle passes downward to the ventricular septum and there 
divides, sending branches to each ventricle, which terminate in 
the Purkinje cells. By way of this bundle the contractions 
which are rhythmically initiated by the sinus node are trans- 
mitted downward over the auricles and ventricles, initiating the 
regular and rhythmical contractions of these chambers. 

Erlanger has shown that by clamping the bundle of His the 
mammalian heart will exhibit the phenomenon of heart-block, 
which constitutes an occasional cause of arrhythmia. 

The myocardium possesses the power of automatically con- 
tracting in regular rhythm, the automaticity residing in the 
myocardium whether it be assumed to be of neurogenic or myo- 
genic character. 

The cardiac action is influenced by and regulated by its nerve 
supply from the cerebro-spinal and sympathetic nervous system. 
Thus it is seen that arrhythmia may be due to alterations in the 
myocardium or to alterations in the nervous control of the 
heart; and that the arrhythmia may appertain to either the 
force of the contractions or to the time sequence of the contrac- 
tions. 

Types of Arrhythmia 

Simple Arrhythmia. — This, the most common type of cardiac 
arrhythmia presents variations both in the frequency and force 
of the cardiac contractions. When the force of the contractions 
is affected the result clinically is the pulsus alternans. When 
the rhythm is the predominant feature influenced, it results in 
variations from the normal rhythm of the cardiac action, which 
in certain instances may be rhythmically irregular, producing the 
pulsus bigeminus or the pulsus trigeminus. 

Intermittence. — In certain cases of cardiac arrhythmia the 
principal feature is the occasional omission of a contraction. 
In such cases it should be determined whether the omission 



AUSCULTATION IN CARDIOVASCULAR DISEASE 227 

of a radial pulse beat is due to the absence or omission of a ven- 
tricular systole or whether due to a ventricular systole which is 
too feeble to produce a radial pulse. 

Respiratory Arrhythmia. — An arrhythmia noticeable during 
expiration often develops as a post-febrile condition. During 
full inspiration, on the contrary, the pulse may be noticed to 
become progressively weaker and may become quite imper- 
ceptible at the wrist, the Paradoxical Pulse. This is noted in 
many young persons, and also occurs in sero-fibrinous and chronic 
adhesive pericarditis. 

Tachycardia (rapid heart) accompanies mental and emotional 
disturbances, after violent physical exertion, during acute fe- 
vers, following the ingestion of large amounts of tea or coffee, 
or the excessive use of tobacco, and during various cardiac neu- 
roses. The cardiac contractions become very rapid, but the 
patient is often not aware of the presence of the condition. Tach- 
ycardia is also noted in cases of exophthalmic goiter and when 
cardiac failure is imminent. 

Paroxysmal Tachycardia, first described by Proebsting, is a 
form of rapid cardiac action characterized by the occurrence of 
paroxysms of very rapid heart action, beginning very abruptly, 
persisting for a variable length of time, and ceasing as abruptly as 
it began. The rhythm of the heart's action is rather markedly 
affected at the commencement and termination of the paroxysm. 
The rate may go above 200 beats to the minute. Usually brief, 
lasting a few seconds or minutes, the attack may persist for 
hours or days. 

Palpitation. — Palpitation is a form of arrhythmia affecting 
chiefly the force of the cardiac contractions, though attended 
usually by disturbances of the rhythm of the heart, The prin- 
cipal feature of the condition is that the subject is painfully con- 
scious of the presence of the tumultuous and irregular heart ac- 
tion. Palpitation is often noted at the onset of menstruation and 
at the climacterium, following excessive indulgence in coffee, tea, 
or tobacco, during attacks of indigestion, in neurasthenic pa- 
tients, and in cases of threatened cardiac failure. 

Bradycardia (Slow Heart). — In bradycardia the heart's action 
is abnormally slow, sometimes less than 50 beats to the minute. 
It is a normal phenomenon in some subjects; it occurs during con- 
valescence from certain febrile diseases, notably after typhoid 
fever. It is also an accompaniment of increased intracranial 
tension in meningitus, cerebral abscess, or depressed fracture of 



228 PHYSICAL DIAGNOSIS 

the skull. It forms a prominent feature of Stokes-Adams Dis- 
ease, a syndrome in which the auricles and ventricles contract 
each with an independent rhythm, the ventricular contractions 
being greatly diminished in frequency. Associated signs com- 
prise Cheyne-Stokes Respiration, apoplectiform seizures, uncon- 
sciousness, and transient paralyses. 

Heart Block. — Heart block, due to diminution of the conduc- 
tivity of the auriculo-ventricular bundle of His, may be partial 
or complete. In partial heart block only a portion of the auricu- 
lar contraction waves are conducted to the ventricles, resulting 
in a diminution of the number of ventricular systoles, the ven- 
tricle contracting only with every second, third, or fourth sys- 
tole of the auricle. 

In complete heart block none of the auricular contraction 
waves are conducted to the ventricle with the result that the 
auricles and ventricles contract independently and rhythmically. 

Extra-Systolic Arrhythmia. — Under certain conditions which are 
but imperfectly understood the auricular or ventricular systole is 
preceded by an extra-systole. As stated, the heart always contracts 
with maximum force regardless of the strength of the stimulus 
exciting the contraction ; and a stimulus reaching the auricle or 
ventricle between the reception of the primary stimulus and the 
completion of the consequent contraction is without effect upon 
the myocardium, the so-called refractory period of the heart. 
When under these conditions an extra-systole is injected into 
the cardiac cycle, causing a diminution in the physiolotic re- 
fractory period, then the succeeding pause preceding the next 
regular systole is increased, the so-called compensatory pause. 
This gives rise to an apparent omission of the next regular ven- 
tricular contraction and produces arrhythmia, which may in 
certain instances be allorhythmic. The clinical significance of 
this type of arrhythmia is little understood; but it has not been 
demonstrated that it is indicative of any grave change in the 
myocardium. 

Embryocardia. — In the course of prolonged continuous fevers, 
and in the presence of myocardial disease with imperfect com- 
pensation or advanced arterial sclerosis when cardiac failure is 
imminent, the rhythm of the cardiac action is altered, approach- 
ing the tones of the fetal heart. In this condition the first and 
second sounds approach each other in force and duration, and 
are separated by pauses of equal duration owing to prolongation 
of the first period of repose between auricular and ventricular 



AUSCULTATION IX CARDIOVASCULAR DISEASE 229 

systole, and shortening of the second period of repose following 
ventricular systole. 

Auricular Fibrillation. — In certain late cases of mitral stenosis 
the regular auricular systole is replaced by a series of inco- 
ordinated contractions, the different muscular bundles contract- 
ing independently instead of in unison with the result that the 
auricle remains in a state of diastole, permitting a systolic 
venous pulse to be registered in the jugular vein. This produces 
a type of arrhythmia which is so absolutely irregular as to defy 
description. The term delirium cordis has been applied to de- 
scribe the condition. 

Adventitious Sounds. — Adventitious sounds are abnormal 
sounds originating within the heart (endocardial) ; or outside 
the heart in the pericardium, lung, pleura, or vessels (exocardial). 

ENDOCARDIAL MURMURS 

Murmurs are abnormal sounds, arising within the chambers 
of the heart, which may be superadded to the normal cardiac 
sounds, or may entirely replace these sounds. The manner of 




Fig. 112. — Physical basis of murmurs due to diminution of lumen. (From Cabot.) 

generation of endocardial murmurs may be explained upon cer- 
tain physical principles. They are produced by irregularities 
in the movement of the blood through the chambers and orifices 
of the heart by virtue of which the blood is set in vibrations, 
which when transmitted through the thoracic wall are audible 
as murmurs and palpable as thrills. As long as normal blood 
passes through a normal heart with normal endocardium and 
normal valves no sound is generated save the sound normally 
produced by the closure or co-aptation of the valve segments. 
But when the blood is forced through a narrowed or stenosed ori- 
fice into the wider chamber beyond, or when the blood is per- 
mitted by an incompetent auriculo-ventricular valve to regur- 
gitate into an auricle the blood column is whipped into eddies 
the so-called " fluid veins" which throw the blood into rapid 
vibrations which are transmitted through the stethoscope to the 
ear as an appreciable sound. 

The sound or murmur is ordinarily propagated in the direc- 



230 PHYSICAL DIAGNOSIS 

tion of the fluid veins. Thus, in the case of the murmur of aor- 
tic stenosis the murmur is transmitted in the direction of the 
blood current, namely upward into the carotid arteries ; whereas 
in the case of the murmur of aortic regurgitation the murmur 
is transmitted in the direction of the regurgitating blood stream, 
namely downward and toward the left. 

The density of the blood influences the generation of mur- 
murs. The thinner the blood, the greater the ease with which 
fluid veins or vibrations are produced in it, which serves to ex- 
plain the great frequency of murmurs occurring in anemic 
states. 

Moreover, a certain degree of blood pressure or endocardial 
pressure is essential to the generation of a murmur. This is evi- 
denced by the fact that endocardial murmurs remain distinct 
and strong as long as cardiac compensation is maintained, to be- 
come indistinct or lost with cardiac dilatation. 

Characteristics of Endocardial Murmurs 

Endocardial murmurs possess certain characteristics or prop- 
erties which are and remain characteristic of the murmurs aris- 
ing at the several valves of the heart, and by a study of which 
the murmurs may be distinguished and their site of production 
may be determined. 

Point of Maximum Intensity. — Every end o cardiac murmur has 
a point of maximum intensity, the point at which it is most clearly 
audible upon the chest wall. These points correspond very 
closely as a rule with the points at which the closure of the nor- 
mal valve in question is best heard, that is, in the four acoustic 
valve areas. Thus, a murmur which is generated at the mitral 
valve is usually heard with the 'greatest intensity at the mitral 
area, over the apex of the heart, whereas a murmur produced 
at the aortic valve is most clearly audible at the aortic valve 
area below the second right costal cartilage near the right ster- 
nal margin. 

This selective transmission of the sound in the case of the 
different murmurs to a particular area of the thorax is ac- 
counted for by the fact that the sound is most likely to travel in 
the direction of the fluid vein, and by the difference in the con- 
ductivity of the component portions of the chest wall, and the 
distance of the cavity in which the murmur is generated from 
the chest wall. 



AUSCULTATION IN CARDIO-VASCULAR DISEASE 231 

Line of Transmission. — Most organic endocardiac murmurs 
are audible not only at their points of maximum intensity, but 
are transmitted or propagated thence in directions which, vary 
in the individual murmurs, the line of transmission, or line of 
propagation of the murmur. The direction in which a given mur- 
mur is to be transmitted is determined by the direction of the 
blood current, and the relative conductivity of the adjacent 
thoracic structures. 

Time of Murmurs. — Every murmur bears a definite relation to 
the events of the cardiac cycle. A murmur which is audible 
during systole is termed a systolic murmur; while one develop- 
ing and audible during diastole is designated a diastolic murmur. 
A murmur which is audible just prior to systole is termed a pre- 
systolic murmur. 

The Quality of Murmurs. — Murmurs are described as harsh 
and rasping, or as soft, blowing, and musical. The finality of a 
murmur possesses diagnostic significance and should in all in- 
stances be studied. As a general rule a harsh unmusical mur- 
mur accompanies stenotic lesions, while soft musical or blowing 
murmurs characterize regurgitant lesions of the valves. While 
studying the quality of the murmur the examiner should en- 
deavor to determine whether the murmur is followed by the 
normal cardiac sound or whether it entirely replaces this sound. 
A murmur which merely accompanies or is added to the normal 
cardiac sound is not of as grave prognostic significance as is a 
murmur which entirely displaces the sound. 

Intensity of the Murmur. — Just as a certain degree of endo- 
cardial pressure is essential to the development of a murmur, the 
intensity of a murmur is a good index to the endocardiac pres- 
sure and hence of the state of the myocardium. Thus, a loud 
murmur suggests the presence of cardiac hypertrophy, while a 
faintly audible murmur is very suggestive of cardiac dilatation. 
Moreover, a change in the intensity of a murmur during daily 
examinations affords an index to the reserve power of the heart, 
a change from a loud to a soft faint murmur suggesting a fail- 
ing heart, while a steady increase in the intensity of a mur- 
mur from day to day is suggestive of cardiac improvement. 

MITRAL MURMURS 

Murmurs arising at the mitral valve are pre-systolic or systolic, 
as they are audible just prior to or during ventricular systole. 



232 



PHYSICAL DIAGNOSIS 



Mitral Pre-Systolic Murmur.— A pre-systolic murmur at the 
mitral area is indicative of mitral stenosis, the narrowing of the 
orifice whipping" the blood stream into fluid veins which pro- 
duce a murmur which is audible just prior to the first sound of 
the heart. The murmur is commonly followed by a sharp first 
sound; but as mitral stenosis and insufficiency frequently co- 
exist, the regurgitant murmur frequently masks or impairs the 
first sound at the apex. The point of maximum intensity of the 
murmur is located at the mitral area over the cardiac apex; 
whence it is not transmitted. The mitral pre-systolic murmur is 
loud and harsh, crescendo in quality, increasing in intensity to 




Fig. 113. — Point of maximum intensity of the mitral pre-systolic murmur. 



its abrupt termination usually in a sharp first sound. The mur- 
mur is quite constantly accompanied by a thrill. The pulmonic 
second sound is accentuated as a result of increased pressure in 
the pulmonary circuit. 

The murmur of mitral stenosis must be differentiated from the 
Flint murmur, which is also audible in the mitral area in cases of 
aortic regurgitation. The manner of production of this mur- 
mur is a matter of dispute, but the usual explanation is that in 
this disease the aortic cusp of the mitral valves becomes the 
target for two streams of blood, entering the ventricle from op- 
posite directions, one entering from the left auricle the other 
regurgitating from the aorta, and is thereby thrown into vibra- 



AUSCULTATION IX CARDIO-VASCl LAR DISEASE 



233 



tions, which are audible as a late diastolic or pre-systolic mur- 
mur. The Flint murmur has its point of maximum intensity at 
the mitral area, is audible during late diastole or just prior to 
systole; is not transmitted therefrom; but it has not the ingraves- 
cent or crescendo quality of the mitral stenotic murmur; it is 
not followed by a snappy first sound; it is not accompanied by a 
thrill ; and has associated with it otli<-r signs of aortic regurgi- 
tation, as pulsations in the arteries of the neck, the water- 
hammer or Corrigan pulse, and the capillary pulse of Quincke. 
Mitral Systolic Murmur. — A initial systolic murmur indicates 
incompetence or insufficiency of the mitral valve, due to organic 




Fig 114. — Point of maximum intensity and line of transmission of mitral systolic 

murmur. 



deformity of the valve segments, or stretching of the mitral 
ring, as a result of which the edges of the cusps cannot be 
brought into close co-aptation during ventricular systole, and 
reflux of blood occurs into the left auricle. The point of maxi- 
mum intensity of the murmur is situated at the mitral area 
over the cardiac apex, whence it is transmitted toward the left 
axillary region, not infrequently as far as the angle of the 
scapula. The murmur occurs during ventricular systole, mask- 
ing or replacing the first sound of the heart at the apex. In 
quality the murmur is soft and sometimes musical, or blowing, and 
of low pitch. The intensity of the mitral systolic murmur varies 



234 PHYSICAL DIAGNOSIS 

with the state of the ventricular musculature, remaining strong 
as long as compensation is maintained, becoming weak or disap- 
pearing when dilatation supervenes. 

The pulmonic second sound is accentuated owing to right ven- 
tricular hypertrophy or raised arterial pressure in the pulmonary 
circulation; and, in long-standing cases with organic change in 
the mitral valve, a safety-valve leak develops at the tricuspid 
valve. 

The murmur of mitral regurgitation is less constantly ac- 
companied by a thrill than is the murmur of stenosis of this 
valve. 

AORTIC MURMURS 

Murmurs arising at the aortic orifice are systolic and diastolic, 
as they are occasioned by an obstruction to the free flow of blood 
from the ventricle into the aorta during ventricular systole, or by 
lesions of the valve which, by impairment of its integrity, permit 
a portion of the blood expelled during systole to regurgitate into 
the ventricle during diastole. 

Aortic Systolic Murmur. — A systolic murmur at the aortic 
valve area is usually indicative of an obstacle to the passage of 
blood into the aorta during ventricular systole. This obstruc- 
tion is usually a sequence of ulcerative endocarditis, which 
causes adhesions to form between the edges of the cusps, thus 
narrowing the orifice. A similar murmur may be caused by 
relative stenosis, in which event the aortic ring and cusps are nor- 
mal, but there is a dilatation or aneurism of the aorta imme- 
diately beyond the valve, A systolic murmur at the aortic area 
may be indicative of aortic roughening. 

The murmur is most clearly heard at the aortic area in the 
second right interspace close to the sternum, whence it is trans- 
mitted upward into the great vessels of the neck. The murmur 
develops during ventricular systole, and may or may not be 
followed by a clear second sound. In murmurs due to deformed 
valve cusps the second sound is usually replaced by a diastolic 
murmur due to aortic regurgitation; but in cases in which the 
systolic murmur is caused by dilatation or roughening of the 
aortic wall the second sound is clear. 

The murmur is loud, harsh, and unmusical, the intensity de- 
pending upon the degree of contractile power of the ventricular 
musculature. 

Aortic Diastolic Murmur. — A diastolic murmur at the aortic 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



235 



area indicates aortic insufficiency or Corrigan's disease. The 
underlying lesion may be a shrinking and thickening of the 
cusps, rupture or perforation of a cusp, or the presence of warty 
vegetations upon the cusps which prevent their close and ac- 
curate co-aptation during diastole. Or again, the murmur may 
arise as the result of the inability of normal valve cusps to close 
an abnormally large aortic orifice (relative insufficiency). 

The murmur is" most distinctly audible at the aortic area, being 
propagated therefrom downward along the right border of 
the sternum. While this murmur is usually most intense at the 
aortic area, in certain instances it is heard most clearly over the 





Fig. 115.— Point of maximum intensity Fig. 116. — Points of maximum intensity 

and line of transmission of aortic systolic and lines of transmission of aortic diastolic 

murmur. murmur. 



gladiolus, just below the Angle of Louis, or over the cardiac 
apex, whence it is transmitted downward and toward the left 
axilla. The murmur occurs during diastole, masking or re- 
placing the second sound at the aortic area. The murmur is 
loud and blowing but not harsh or unmusical. 

While the diastolic murmur of aortic insufficiency may occur 
alone, it is not infrequently accompanied by a systolic aortic 
murmur, due to aortic stenosis, a deformity of the aortic valves 
underlying both conditions and causing both stenosis and insuf- 
ficiency. In such event there is a double murmur generated at 
the aortic valve, harsh during systole, and less so during diastole. 



236 



PHYSICAL DIAGNOSIS 



Such a double murmur must not be confused with a pericardial 
friction rub with its to-and-fro rhythm. 

TRICUSPID MURMURS 

Murmurs at the tricuspid area are infrequent ; but when pres- 
ent they are pre-systolic and systolic. 

Tricuspid Pre-systolic Murmur.— A pre-systolic murmur aris- 
ing at the tricuspid valve is indicative of tricuspid stenosis. The 
lesion is usually a congenital condition, very rarely encountered 
in an acquired form. 

The murmur is best appreciated at the tricuspid valve area 




Fig. 117. — Point of maximum intensity of 
tricuspid pre-systolic murmur. 



Fig. 118. — Point of maximum intensity 
and line of transmission of tricuspid sys- 
tolic murmur. 



over the lower portion of the sternum, whence it is not transmitted, 
In quality, time, and intensity it is the counterpart of the mur- 
mur of mitral stenosis. The murmur is usually associated with a 
thrill over the tricuspid area together with an enfeebled pul- 
monic second sound and dyspnea. 

Tricuspid Systolic Murmur. — A systolic murmur at the tri- 
cuspid area occurs with tricuspid regurgitation. The causative 
lesion may be a deformity of the cusps of the valve the sequence 
of acute endocarditis. More commonly a systolic murmur at this 
valve is relative, the result of increased blood pressure in the 



AUSCULTATION IX CARDIOVASCULAR DISEASE 



237 



right ventricle and pulmonary circulation the sequence of an 
obstructive disease of the lung or mitral insufficiency. 

This murmur is best heard at the tricuspid area, whence it is 
transmitted upward and toward the right. It corresponds to 
the systole of the ventricle, replacing or masking the first sound 
at the tricuspid area. It is a soft, blowing murmur of moderate 
intensity. It is accompanied by systolic pulsation in the jugular 
veins and pulsation of the liver. 

PULMONARY MURMURS 

Murmurs at the pulmonary area are of very frequent occur- 
rence, but organic disease of this valve is very rare. Most of 




O- 



) 







Fig. 119. — rPoint of maximum intensity 
and line of transmission of pulmonic sys- 
tolic murmur. 



Fig. 120. — Point of maximum intensity 
and line of transmission of pulmonic dias- 
tolic murmur. 



these murmurs are functional, and will be discussed in a sub- 
sequent section. The murmurs generated at the pulmonic valve 
are systolic and diastolic. 

Systolic Pulmonic Murmur. — A systolic murmur at the pul- 
monary valve is rarely encountered and when it is found, it 
signifies pulmonary stenosis, a congenital lesion. The murmur 
occurs during ventricular systole, is most intense over the pul- 
monic area in the second left interspace adjacent to the ster- 
num, is harsh and unmusical and is transmitted upward into the 
root of the neck. 



238 PHYSICAL DIAGNOSIS 

Diastolic Pulmonic Murmur. — A diastolic murmur at this valve 
represents pulmonary regurgitation, due to alteration in the 
integrity of the cusps of the valve, incident to acute endocar- 
ditis or due to dilatation of the orifice so that the normal cusps 
cannot close the opening (relative insufficiency). 

The point of maximum intensity of the murmur is situated at 
the pulmonic area, whence the murmur is propagated down- 
ward along the left sternal border. The murmur occurs during 
diastole, masking or replacing the second sound at the pul- 
monic area. The murmur in quality resembles the murmur of 
aortic regurgitation, being not unmusical and soft. 

FUNCTIONAL MURMURS 

Functional murmurs, also known as inorganic, accidental, 
or hemic murmurs, are endocardiac murmurs arising in a heart 
which is not the seat of any structural change. Functional mur- 
murs are not caused by valvular deformity, but are due to ex- 
cessive fluidity of the blood incident to anemia, to temporary 
myocardial weakness during the course of acute fevers, to car- 
diac neuroses, or to stretching of the valvular orifices due to great 
physical exertion. These murmurs are audible most frequently 
at the pulmonic area, and least frequently at the aortic area. 
They are more common at the mitral than at the tricuspid area. 

Functional murmurs are transient, coming and going, but not 
persisting for any great length of time. They are always sys- 
tolic and are not transmitted beyond the precordia. They are 
encountered most frequently in association with states of anemia 
and asthenia. Functional murmurs are soft and of low. pitch; 
and when due to anemia are often accompanied by the humming 
top murmur in the jugular veins. 

MULTIPLE MURMURS AND THEIR DIAGNOSIS 

While the organic and functional murmurs arising at the va- 
rious valves and orifices of the heart are separate entities, it is 
to be borne in mind that two or more of these murmurs may co- 
exist in the same patient, the differentiation of which is often at- 
tended with not a little difficulty. 

When two distinct murmurs are encountered at two heart 
valves as for instance at the aortic and mitral valves, the mere 
presence of two murmurs at two valves does not necessarily sig- 



AUSCULTATION IN CARDIOVASCULAR DISEASE 239 

nify organic disease of both valves, as one murmur may be rela- 
tive on account of the dilatation of the left ventricle as the re- 
sult of the aortic lesion. The mitral murmur in this instance is 
functional, and the aortic murmur is organic. Similarly, an 
organic mitral insufficiency is frequently followed by a func- 
tional tricuspid regurgitation. 

An accurate diagnosis of multiple murmurs is difficult. When 
two murmurs occur at two phases of the cardiac cycle, one sys- 
tolic, and the other diastolic, this fact is of great assistance. 
When two murmurs at the same period of the cardiac cycle are 
discovered, the differentiation must pest largely upon the points 
of maximum intensity and the lines of transmission of the dif- 
ferent murmurs. The quality of the murmurs is of some a^ 
ance, remembering the general rule that stenotic murmurs are 
harsh, while regurgitant murmurs are usually musical. If, in 
the case of two murmurs one be harsh and the other musical, 
there are certainly two murmurs. If, on the contrary, both are 
alike in quality, it is possible that there is only one murmur, 
which is transmitted from the orifice where it is produced to a 
second orifice. 

Moreover, murmurs arising in the heart must he differentiated 
from a possihle cardiorespiratory murmur by directing the 
patient to suspend respiration, whereupon the latter will dis- 
appear. 

Finally, in the differentiation of multiple murmurs the auscul- 
tatory findings must he correlated with the general appearance 
of the patient, and such accessory signs as edema, dyspnea, and 
cyanosis. 

Cardio-Respiratory Murmur. — The cardiorespiratory murmur 
is a systolic blow or whiff audible in the mitral area over the 
cardiac apex, closely simulating an endocardiac murmur. The 
sound is produced by the impulse of the heart against a portion 
of lung anchored in front of the heart by a pleural adhesion or 
hypertrophic emphysema. The sudden expulsion of the air from 
the portion of lung by the impact of the heart generates a sound 
closely simulating an endocardial murmur. 

Pericardial Friction. — During inflammations of the pericar- 
dium the surfaces of the visceral and parietal membranes, which 
glide noiselessly over each other in health, become roughened 
and produce a friction sound, which in some instances closely 
simulates an endocardial murmur. The pericardial friction sound 
has a to-and-fro rhythm dependent upon the contractions of the 



240 PHYSICAL DIAGNOSIS 

heart, which are not precisely synchronous with the heart sounds 
as are endocardial murmurs, but last longer than do the 
heart sounds. The sound is very variable, being exaggerated by 
moderate pressure with the stethoscope and being abolished by 
firm pressure with this instrument. It is transient, perhaps pres- 
ent at one examination and absent a few hours later. The rub 
is altered by change of posture, often disappearing when the pa- 
tient assumes the dorsal decubitus, to reappear upon his return 
to the sitting posture. (See Fig. 94, p. 203.) 

The pericardial friction sound is audible all over the precordia, 
but is most intense in the fourth interspace to the left of the 
sternum. The two phases of the sound are of equal intensity, 
but not of equal duration. The sound seems very superficial, 
and is not abolished upon suspension of respiration as is the 
pleural friction rub. 

In pericarditis with effusion, as the fluid accumulates in the 
pericardial sac the friction rub usually disappears, though it is 
not uncommon for it to persist at the base of the heart. 

Pericardial Succussion Sound. — Splashing or succussion sounds 
arising within the pericardium indicate the presence of air and 
fluid, or hydro-pneumo-pericardium. The sounds may be splash- 
ing, bubbling, or gurgling, and have been compared to the sound 
produced by a water-wheel. They are not abolished during suspen- 
sion of respiration. 

VASCULAR MURMURS 

Arterial Murmurs. — Auscultation may reveal the presence of 
murmurs in the aorta, the carotids, subclavian, brachial and 
femoral arteries. In auscultation of an artery the examiner 
should apply the stethoscope over the vessel lightly but firmly, 
yet without exerting sufficient pressure to diminish the lumen 
of the vessel. He should gradually then apply sufficient pressure 
to partially occlude the vessel. During the first maneuver vas- 
cular phenomena may or may not be elicited. In the second ex- 
amination even in a normal artery, a systolic murmur will be 
generated by the partial occlusion of the vessel. This murmur is 
produced by vibrations caused by "fluid veins" which are ini- 
tiated by vibrations set up by the passage of the blood through 
the constricted portion of the vessel into the wider portion be- 
yond. 

The Aorta. — Upon auscultation of the aorta in the left inter- 
scapular region a systolic murmur in the vessel is a sign of aneu- 



AUSCULTATION IN CARDIOVASCULAR DISEASE 241 

rism of the aorta. The murmur is accompanied by concomitant signs 
of aneurism; namely, dullness on percussion, a palpable thrill, 
pulsation of the chest wall in many instances, and pressure symp- 
toms. Frequently there is tracheal tugging, or Oliver's sign. 

The Carotids. — Upon auscultation of the carotid artery the first 
and second sounds of the heart may sometimes be audible, al- 
though the first sound is often absent. These sounds are not to be 
confounded with murmurs; they are merely the normal sounds of 
the heart transmitted along the course of the circulating blood. 
Endocardiac murmurs are similarly transmitted, a harsh systolic 
murmur audible over the vessel signifying aortic stenosis, aortic 
roughening, or aneurism of the arch. The transmitted second 
sound of the heart may be replaced by the diastolic murmur of 
aortic regurgitation. 

The Subclavian Artery. — In certain cases of apical pulmonary 
tuberculosis a systolic murmur is audible in the subclavian artery. 
The murmur in this instance is due to constriction of or bending of 
the lumen of the vessel by the traction of adhesions. A diastolic 
murmur is occasionally audible in the subclavian artery in 
aortic regurgitation or Corrigan's disease. 

The Femoral Artery. — In many eases of aortic regurgitation a 
double murmur, systolic and diastolic, may be elicited by auscul- 
tation over the femoral artery, the systolic murmur resulting from 
the sudden injection of blood into the artery, and the diastolic 
murmur resulting from the reflux of the blood stream which 
the incompetent aortic valve is incapable of sustaining in the 
aorta. This double murmur in the femoral artery constitutes 
Duroziez's sign of aortic regurgitation or Corrigan's disease. 

Venous Murmurs. — A continuous murmur may be elicited over 
the jugular vein in health by tightly applying the stethoscope 
to the vein. A similar murmur may sometimes be generated by 
turning the head far to one side. Hence, in auscultation of this 
vessel the stethoscope should be lightly applied and the head 
maintained in a symmetric and unconstrained position. 

Venous Hum. — The principal diagnostic sign afforded by aus- 
cultation of the venous system is the venous hum, humming-top 
murmur, nun's murmur, or bruit de diable. This murmur is usu- 
ally to be elicited over both jugulars, but is more intense over the 
right vein. The murmur is usually loudest or most intense just 
at the inner third of the clavicle. It is more intense when the 
patient sits upright, during inspiration, and diastole, factors 
which increase the rapidity of the flow of blood through the 



242 PHYSICAL DIAGNOSIS 

veins. The mechanism of production of this murmur has been 
disputed. Occasionally audible in normal subjects, it is almost 
pathognomonic of anemia, particularly chlorosis and pernicious 
anemia. 

In these conditions the increased fluidity of the blood possibly 
plays a leading role in the production of the murmur; and, more- 
over, the diminished nutrition of the vascular wall permits re- 
laxation which favors vibration. 

BLOOD PRESSURE 

Definition. — It is obvious that for the maintenance of a con- 
stant flow of blood through the vessels a certain degree of force 
must be exerted upon the blood column. This force, which 
governs the onward course of the blood, constitutes blood pres- 
sure, and is derived from three principal sources. 

At each contraction of the left ventricle a variable quantity, 
from 80 to 100 c.c. of blood is forced into the aorta. But this 
volume of blood is not injected into an empty vessel. The aorta 
is filled with blood at the commencement of ventricular systole, 
as not sufficient time elapses between the ventricular systoles 
for the blood to flow from the large arteries into the capillaries 
and veins. As a consequence, when the systolic discharge of 
blood from the ventricle occurs, the walls of the large arteries 
yield or are stretched by virtue of the elastic elements which 
they contain. As a result of this elasticity, the vascular walls 
immediately contract upon the contents of the vessels and force 
the blood column onward. 

However, the flow of the blood through the vessels encounters 
a distinct resistance to its onward progress, when the capillaries 
are reached, an obstacle to which the term "peripheral resis- 
tance" is applied. "When it is recalled that the sectional area of 
the capillaries is many hundreds of times as great as that of the 
larger arteries, it is obvious that a considerable degree of fric- 
tion is generated by the passage of the blood through these 
minute vessels. 

Moreover, the arterioles, the immediate precursors of the cap- 
illaries, are supplied with a special nervous mechanism through 
the vaso-motor nervous system, whereby the calibre of these 
vessels may be constricted or dilated, thus producing variations 
in the degree of peripheral resistance. 

Thus, the term blood pressure refers to the interaction of these 



AUSCULTATION IX CABDIO-VASCULAB DISEASE 243 




Fig. 121.— Cook's modification of Riva-Kocci's blood pressure instrument. (From Warfield.) 




Fig. 122. — Stanton's sphygmomanometer. (From Warfield.) 



244 



PHYSICAL DIAGNOSIS 



three factors (ventricular contraction, elasticity of the arteries, 
and peripheral resistance), and clinically it represents the total 
pressure exerted by the heart and blood vessels. 
Determination of Blood Pressure. — Clinically it is desirable to 




Fig. 123. — The Erlanger sphygmomanometer with the Hirschf elder attachments by 
means of which simultaneous tracings can be obtained from the brachial, carotid, and 
venous pulses. (From Warfield.) 



determine the blood pressure during ventricular systole (systolic 
pressure) ; during ventricular diastole (diastolic pressure) ; and 
the difference between these determinations, (pulse pressure). 



AUSCULTATION IN CARDIOVASCULAR DISEASE 



245 




Fig. 124. — The Janeway sphygmomanometer which has been found a convenient and 
practicable instrument. The scale can be pushed below the level of the top of the box, 
the long arm of the mercury tube is disjointed and placed in the bottom of the box, 
the lid is then closed, and the instrument takes up but little space in the physician's bag. 
(From Warfield.) 



246 



PHYSICAL DIAGNOSIS 



Blood pressure is determined .by an instrument, the sphygmo- 
manometer, the procedure being termed sphygmo-manometry. The 
first really accurate and practical sphygmo-manometer was devised 
by Riva-Kocci in 1896. This instrument has been modified by Cook, 
Stanton, Erlanger, Janeway, and Faught, the basis of all in- 





Fig. 125. — -Rogers' "Tycos" dial sphygmomanometer. (From Warfield.) 





Fig. 126. 

Fig. 126. — The Faught blood pressure instrument. An excellent instrument which is 

quite easily carried about and is not easily broken. (From Warfield.) 

Fig. 127. — Detail of the dial in the "Tycos" instrument. (From Warfield.) 

struments of this type consisting of an inflatable rubber bag, con- 
tained in an inelastic leather cuff so that during inflation of the 
bag the entire pressure is exerted upon the encased arm ; a mer- 
cury manometer ; and an air pump so connected by rubber tubing 



AUSCULTATION IX CABDIO-VASCULAB DISEASE 247 




Fig. 128. — Method of taking blood pressure with a patient in sitting position. (From 

Warfield.) 




Fig. 129. — Method of taking blood pressure with patient lying down. (From Warfield.) 



248 



PHYSICAL DIAGNOSIS 



that the air which is pumped is distributed with uniform pres- 
sure to the cuff and the manometer. 

A recently devised instrument, which dispenses with the use 
of the mercury manometer, and which instead of recording the 
pressure in millimeters of a mercury column records the pres- 
sure upon a dial, is the Rogers Tycos Instrument. 

With either type of instrument in recording the blood pres- 
sure two methods may be employed; namely the palpatory 
method; or the auscultatory method. Whichever method is em- 
ployed, certain details of the technic must be observed in order 




Fig. 



130. — Observation by the auscultatory method and a mercury instrument. One hand 
regulates the stopcock which releases air gradually. (From Warfield.) 



to obtain satisfactory results. The cuff should be placed at* least 
two inches above the bend of the elbow; the connections of the 
tubing to the different portions of the instrument should be air- 
tight; the dilatable rubber bag should be adapted to the inner 
portion of the arm, overlying the brachial artery ; the cuff should 
be snugly applied, but not with sufficient force to interfere with 
the venous return; and the lower portion of the cuff should fit the 
arm more loosely than the upper portion. 

Palpatory Method. — When the cuff has been properly fitted 
to the arm and the tubing to the recording instrument, manom- 



AUSCULTATION IN CARDIO-VASCULAR DISEASE 249 

eter or dial, air is pumped into the cuff until the pulse becomes 
inappreciable to the finger palpating the radial artery. When 
the pulse disappears the mercury is pumped up 10 or 15 mm. 
above this point; and the screw is turned and allows the mer- 
cury to drop very . sloAvly. At the instant that the pulse be- 
comes again appreciable at the wrist the release valve is closed 
and the systolic pressure is read upon the scale or dial. 

The principle involved in this procedure is that it requires an 
amount of external pressure to obliterate the pulse in the artery, 
which is commensurate with the intra- vascular pressure during 
systole. 

Having determined the systolic pressure by the method de- 
scribed, the release valve is again slowly rotated, and the column 
or needle allowed to descend upon the scale very slowly, the undu- 
lations of the column or needle being closely observed. The de- 
scent is attended by oscillations: and at one point in the descent 
these oscillations become very pronounced, this point correspond- 
ing to the diastolic pressure, and as a rule being accompanied by a 
larger pulse wave than normal at the wrist. 

By deducting the diastolic pressure from the systolic pressure, 
as recorded, the pulse pressure is obtained. In a healthy adult 
male the systolic blood pressure usually ranges between 120 and 
135 millimeters, though a systolic pressure of 140 in such a 
patient is not necessarily pathologic. The diastolic ranges be- 
tween 90 and 110 millimeters, the pulse pressure usually ranging 
from 25 to 35 millimeters. 

Auscultatory Method. — The auscultatory method of determin- 
ing the blood pressure is more accurate than is the palpatory 
method, and, in addition, shows wider ranges of pressure in the 
individual case. The systolic pressure, as determined by the 
auscultatory method, is always about 5 millimeters above that 
registered by the palpatory method, whereas the diastolic pres- 
sure often ranges 10 to 15 millimeters below that obtained by the 
palpatory method. 

In determining blood pressure by this method the bell of a 
stethoscope is applied over the brachial artery just above the 
bend of the elbow, and the cuff inflated until all sound disap- 
pears. Having attained this point, the air is allowed to slowly 
escape from the cuff, whereupon a series of sounds are heard 
which have been divided into five phases. The first phase is rep- 
resented by the first sound which is heard, which is the proper 



250 PHYSICAL DIAGNOSIS 

point at which to record the systolic pressure. The first phase is 
quickly followed by a peculiar murmuring sound as the tension in 
the cuff is lowered, the second phase; this in turn is followed by a 
sharp, ringing note of increased intensity, the third phase. The 
sharp murmur of the third phase gradually gives place to a less 
intense sound, the fourth phase; this phase lasts until all sound 
ceases, the fifth phase. The diastolic pressure may be recorded at 
the beginning of the fourth phase or at the beginning of the fifth 
phase, the time at which all sound ceases. There is a difference 
of approximately 5 millimeters, as the record is made at the 
fourth or the fifth phase ; but as it is often difficult to say just 
when the fourth phase begins, and as it is relatively easy to de- 
termine when all sound ceases, it is a safe rule to record the dias- 
tolic pressure at the commencement of the fifth phase, bearing 
in mind the discrepancy between the reading at the two phases. 

Normal Variations. — Before drawing conclusions from varia- 
tions in blood pressure, certain normal variations must be elim- 
inated. Thus, the pressure varies with the attitude assumed by 
the patient, being higher when he stands, and lower when the 
sitting or recumbent attitude is assumed. Clinically the blood 
pressure may be estimated with the patient either in the sitting 
or recumbent posture with equally satisfactory results; but which- 
ever attitude is assumed at the first estimation should be em- 
ployed in all subsequent examinations. After a full meal the 
blood pressure is slightly higher than it is several hours after a 
meal; and during sleep it is normally lower than during waking 
hours. Exercise, nervous excitement, and the ingestion of stimu- 
lants increases the blood pressure temporarily. Similarly, high 
altitudes raise the blood pressure temporarily. 

Pathological Variations. — When a high systolic pressure is 
encountered in a patient who is and has been at rest, it usually 
points to cardiac hypertrophy, the causes of which are varied ; to 
arterio-sclerosis, to nephritis, or brain tumor, or apoplexy. In 
female subjects, it may point to threatened eclampsia. In car- 
dio-vascular disease a high systolic pressure which is accom- 
panied by an increased pulse pressure usually is indicative of 
adequate compensation; whereas a normal systolic pressure with 
a decreased pulse pressure points to threatened cardiac failure. 

A decrease in the systolic pressure accompanies conditions of 
shock and collapse, internal hemorrhage, and the vascular asthe- 
nia of Addison's disease. In the course of typhoid fever a sud- 



AUSCULTATION IN CARDIO-VASCULAR DISEASE 251 

den drop in the systolic pressure is suggestive of perforation. 
A low systolic pressure is often an early sign of phthisis. 

The importance of variations in the diastolic pressure has come 
to be generally recognized. The diastolic pressure represents the 
dcu tee of peripheral resistance which must be overcome before 
the left ventricle may discharge its contents; and if this pres- 
sure is raised, as it usually is in arterial fibrosis and chronic 
interstitial nephritis, an added burden is thrown upon the heart 
before the blood can begin to circulate. Moreover, when a high 
diastolic pressure is encountered, it is of great importance from 
the standpoint of prognosis and treatment to determine whether 
this increase is due to functional angiospasm or to organic disease 
of the arterial system. In aortic regurgitation the diastolic pres- 
sure is low, while the pulse pressure is increased to a correspond- 
ing degree. 

The pulse pressure deserves careful study in all cases in which 
sphygmomanometry is practiced. The pulse pressure represents 
the contractile power of the left ventricle in excess of the diastolic 
pressure; or, in other words, the power of the left ventricle over 
and above the peripheral resistance to the circulation of the 
blood. Thus, in the course of lobar pneumonia, when the heart 
is laboring under an increased load, a daily record of the pulse 
pressure gives valuable information as to the state of the myocar- 
dium, and affords a valuable prognostic and therapeutic index. 
As the overtaxed heart gradually fails, the systolic pressure 
gradually approximates the diastolic pressure, the pulse pres- 
sure steadily diminishing- until it is nil, the point at which life 
becomes impossible. 

Venous Pressure. — Hooker, who has devised an apparatus 
which permits the recording of the venous pressure, states that 
there is a progressive rise of venous pressure from youth until 
old age. He also finds that just before death there is a rapid 
rise of the venous pressure. Clark* states that a venous pressure 
of 20 centimeters of water represents the limit between adequate 
compensation and decompensation of the heart, and that a rise 
above this point is apt to be followed by cardiac failure. 

A rough estimate of the venous pressure may be made by ob- 
serving the superficial veins upon the back of the hand when the 
hand is raised above the level of the heart. Xormallv these veins 



*Arch. Int. Med., Oct., 1915. 



252 PHYSICAL DIAGNOSIS 

should collapse when the hand is raised above the level of the 
heart, and they should practically collapse with the hand at the 
level of the cardiac apex. But in the presence of increased 
venous pressure the veins fail to collapse when the hand is 
raised even above the level of the heart. Oliver states that the 
venous pressure may be estimated in millimeters of mercury by 
multiplying by 2 each inch above the level of the cardiac apex in ' 
which the veins collapse. 



SECTION V 
DISEASES OF THE CIRCULATORY ORGANS 



CHAPTER XVII 
DISEASES OF THE PERICARDIUM 

PERICARDITIS 

Inflammation of the pericardium occurs primarily and as a 
secondary disease. Primary pericarditis may be caused by trauma 
to the pericardium from without or from within the thorax. Cer- 
tain cases of so-called idiopathic pericarditis develop in children 

without assignable cause. 

Secondary pericarditis may be a sequence of rheumatism, ton- 
sillitis and other septic states, acute fevers, gout, tuberculosis, 
and in the course of arterio-sclerosis. 

Pericarditis is commonly classified as: Acute fibrinous peri- 
carditis; sero-fibrinous pericarditis, or pericarditis with effusion; 
and chronic adhesive pericarditis. 

Acute Fibrinous Pericarditis 

Pathology. — In this form of pericarditis, which is also termed 
pericarditis sicca, the surface of the visceral pericardium and 
later of the parietal pericardium loses its normal glistening 
smooth appearance, and becomes roughened. It is the seat of a 
fibrinous exudate, which may be circumscribed, involving only 
a small portion of the membrane, or may be universal, involving 
the entire pericardial surface. There is usually a small quantity 
of fluid admixed with the exudate ; but in tuberculous cases it 
may be quite dry. The roughened, exudate-clothed pericardium 
does not glide noiselessly as is the case in health; but instead 
produces a friction rub. 

The appearance of the pericardial surfaces varies in different 
stages of the disease. Thus, in a fairly early case the surfaces 

253 



254 



PHYSICAL DIAGNOSIS 



appear like two pieces of bread and butter which have been 
apposed and pulled asunder, the " bread and butter" stage. In 
other instances the exudate is rolled into irregular folds upon 
the pericardial surface, constituting the cor villosum. 

The subjacent myocardium is involved to a variable extent in 
the inflammatory process, presenting infiltration with leuko- 
cytes. Endocarditis is a frequent accompaniment, but does not' 
arise by extension of the pericardial inflammation. 

Physical Signs. — Inspection. — In acute fibrinous pericarditis 
inspection is usually negative, though it may reveal the presence 




Fig. 131. — Acute fibrinous pericarditis. (From McFarland.) 

of dyspnea and perhaps this will amount to orthopnea. The 
cardiac impulse is accentuated in force, and perhaps in extent. 
The facial expression is anxious. 

Palpation reveals the presence of pericardial friction fremitus, 
which is increased by having the patient bend forward. The pulse 
is accelerated, and is apt to be of the pulsus paradoxus type. 

Percussion reveals no deviation from the normal, as the heart 
is not enlarged in acute fibrinous pericarditis. 

Auscultation shows the presence of the pericardial friction rub. 
As stated in a previous section, this rub is very variable, being 



DISEASES OF THE PERICARDIUM 255 

increased by moderate pressure and abolished by strong pressure 
with the stethoscope ; also varying in intensity upon change of 
posture, and varying from day to day in intensity; also, as stated 
in a previous section, corresponding roughly with the systole and 
diastole of the heart, but not as accurately as do endocardial mur- 
murs, lasting longer than do the Ik art sounds. Although its sys- 
tolic and diastolic phases have the same intensity, they are usually 
of unequal length. It is confined to the precordia and is not 
transmitted thence, as are endocardial murmurs. If the asso- 
ciated effusion becomes great, the friction rub disappears, but not 
infrequently remains audible over the base of the heart. The 
quality of the friction rub has been compared to the creaking of 
the leather of a new leather saddle. These friction sounds are 
usually best heard to the left of the sternum in the fourth and 
fifth interspaces or near the aortic valve area. In other instances 
it is most audible at the apex area. The friction sound seems 
very superficial, as if it were just beneath the ear. The peri- 
cardial friction rub usually presents two phases, systolic and 
diastolic; sometimes only a single phase; in other instances three 
phases, simulating a sort of canter rhythm or gallop rhythm 

Diagnosis. — The diagnosis of acute fibrinous pericarditis is 
very easy when the disease is suspected and the friction rub, the 
pathognomonic sign is sought for. But, arising as it does, dur- 
ing some acute infection it is often masked by the other symp- 
toms of the disease and is not suspected nor sought for, hence 
is overlooked. 

A mistake may arise in failing to differentiate acute fibrinous 
pericarditis from organic disease of the aortic valve, or from 
pleuro-pericardial friction in pleurisy arising during pneumonia 
or tuberculosis. Thus organic disease of the aortic orifice pro- 
ducing a double murmur, systolic and diastolic in time, with a 
palpable thrill may be easily mistaken for the two phases of the 
pericardial friction rub. But this double murmur corresponds 
more closely with the cardiac systole and diastole; the murmurs 
are transmitted from the precordia in different and definite lines ; 
and produce alterations in the character of the pulse, as for in- 
stance the water-hammer pulse in Corrigan's disease, and the 
small, wiry pulse of aortic stenosis. The close localization or cir- 
cumscription of the murmur to the aortic orifice is of aid in dif- 
ferentiation, and, moreover, aortic disease causes hypertrophy 
and perhaps ultimately dilatation of the heart. The pericardial 
friction sound is more superficial and variable than is the aortic 



256 PHYSICAL DIAGNOSIS 

murmur, and is influenced bw pressure with the stethoscope, 
which does not influence the murmur of organic disease of the 
aortic valve. 

The pleuro-pericardial friction rub somewhat resembles the peri- 
cardial friction rub, but it disappears during suspension of the 
respiration following full inspiration. 

Acute fibrinous pericarditis is accompanied by pain over the 
precordia or around the xyphoid appendix, and moderate fever. 

Sero-Fibrinous Pericarditis (Pericarditis with Effusion) 

Pathology. — Sero-fibrinous pericarditis begins as a dry peri- 
carditis, the pericardial layers being covered with fibrinous ex- 
udate. Soon, however, there is an exudation of sero-fibrinous 
fluid, which fills the pericardial sac more or less completely. 
This fluid is often turbid, containing flocculi of fibrin. The quan- 
tity of the fluid varies from 200 cubic centimeters to tAvo liters or 
more. In some cases there are only a few cubic centimeters of 
the fluid. The fluid may be completely absorbed with little 
permanent damage to the pericardium; but occasionally adhe- 
sions form between the visceral and parietal layers, and in other 
cases there are left localized areas of pericardial thickening, the 
so-called milk spots, or soldier spots. The subjacent myocardium 
is inflamed to a variable extent, and endocarditis, is sometimes a 
concomitant condition, but never by extension of the inflamma- 
tion through the myocardium. 

Physical Signs. — Inspection. — Sero-fibrinous pericarditis pro- 
duces a variable extent of precordial bulging, most pronounced 
in young children and thin chested individuals. The cardiac im- 
pulse may be invisible, or there may be a wavy impulse in the 
third and fourth intercostal spaces to the left of the sternum. 
In large effusions the epigastrium bulges. The expansion of the 
left lung is diminished by pressure of the lung by the effusion. 
The diaphragm and left lobe of the liver are depressed, adding 
to the epigastric prominence. Precordial bulging is usually con- 
fined to children, whose thoracic parietes are resilient, the 
rigid chest Avails of adults not bulging readily. If the apex beat 
is present, it is enfeebled. In extensive effusion there is epi- 
gastric bulging AA T hich constitutes Auenbrugger's sign. There is 
dyspnea, sometimes orthopnea. Precordial bulging is noted in 
women as AA^ell as in children. When the cardiac impulse is in- 
visible it may in some instances be made visible by having the 
patient bend forAvard. Tortuosity of the superficial veins some- 



DISEASES OF THE PERICARDII M 257 

times occurs as a result of intra-thoracic pressure of the effusion. 

Palpation confirms displacement of the apex, which is sometimes 
abnormally low. Early in the disease a friction rub is palpable, 
which disappears as the effusion develops, though it sometimes 
persists at the base, to reappear with absorption of the effusion. 
As to intensity, the cardiac impulse is feeble, and gradually de- 
creases in intensity as the effusion develops, to finally disappear 
altogether. Ewart has noted that the first rib is palpable at its 
chondro-sternal articulation in pericarditis with effusion, the 
"first rib sign." Fluctuation can be obtained in only rare in- 
stances of large effusion. Epigastric tenderness upon palpation 
is frequent. 

The pulse is usually weak and of small volume, often irregular, 
and of the pulsus paradoxus type, gradually becoming progres- 
sively weaker during full inspiration. 

Percussion. — The area of heart dullness is increased, and this 
increases gradually and progressively as the effusion progress* - 
The shape of the area of dullness is pear-shaped with its base 
directed downward toward the diaphragm. In the fifth inter- 
space the dullness extends one or two Lnches to the right of the 
sternum constituting Rotch's sign. On the left side the dull- 
ness ma} 7 extend outward beyond the apex of the heart or even 
into the axilla. Also the dullness of a Large effusion may en- 
croach upon and obscure the normal gastric tympany in Traube's 
semilunar space. The diaphragm and left lobe of the liver are 
depressed. Gerhardt has pointed out that when the patient is 
upright the area of dullness is broader than when he is recum- 
bent. A co-existing emphysema may serve to obscure the dull- 
ness of a fairly large pericardial effusion. 

The increase in heart dullness usually occurs in all directions, 
but in many cases it is increased only to the left side and up- 
ward. Rotch's sign is an extension of the dullness into Egstein's 
cardio-hepatic angle, and this is often an early sign of the 
disease. 

Auscultation. — In the early stages of the disease prior to the de- 
velopment of the effusion, a friction sound is audible over the 
precordia. "When the effusion develops this friction rub disap- 
pears gradually, although frequently being still audible at the 
base. If inaudible when the patient is in. the recumbent posture, 
it sometimes appears when he is in the sitting posture. The 
cardiac sounds become gradually weakened and muffled as the 
effusion develops. The pulmonic second sound is apt to be ac- 



258 PHYSICAL DIAGNOSIS 

centuated. The crowding of the left lung may cause bronchial 
breath sounds in the axillary region. 

Diagnosis. — The pear-shaped area of increased cardiac dullness, 
the initial friction rub, disappearing with development of the 
effusion, the muffled and faint character of the heart sounds, 
with pain over the precordia, aggravated by pressure over the 
lower end of the sternum, dyspnea, cyanosis, the paradoxic pulse, 
and fever, point to effusion into the pericardial sac. 

Dilatation of the heart produces increase in the area of heart 
dullness and must be differentiated from pericardial effusion. 
Concerning these two conditions Osier lays down six rules of dif- 
ferential diagnosis: 

1. The character of the impulse, which in dilatation is com- 
monly visible and wavy. 

2. The shock of the cardiac sounds is more distinctly palpable 
in dilatation. 

3. The area of dullness in dilatation rarely has a triangular 
form ; nor does it, except in cases of mitral stenosis, reach so high 
along the left sternal margin or so low in the fifth and sixth 
interspaces without visible or palpable impulse. An upper limit 
of dullness shifting with change of position speaks strongly for 
effusion. 

4. Rarely in dilatation is the distention sufficient to compress 
the lung and produce the tympanitic note in the axillary region. 

5. In dilatation the heart sounds are clearer, often sharp, val- 
vular, or fetal in character; gallop rhythm is common, whereas 
in effusion the sounds are distant and muffled. 

6. The x-ray picture may be very definite and unlike any 
form of dilatation of the heart. (Osier.) 

Pleurisy with effusion sometimes requires to be differentiated 
from pericardial effusion when this is very large. In left sided 
pleural effusion, unless the effusion assumes the encysted form, it 
is apt to be mistaken for a large pericardial effusion; and similarly 
a large pericardial effusion may be difficult to differentiate from 
a left sided pleural effusion. But in pleurisy with effusion the 
cardiac impulse is displaced; the flatness extends around the side 
of the chest ; the compressed lung gives skodaic resonance in the 
infra-clavicular and mammary regions; Traube's semilunar space 
of tympany is obliterated; and the spleen is apt to be displaced 
downward. In pericarditis with effusion, on the contrary the ef- 
fusion is apt to extend well to the right of the sternum (Rotch's 
sign), which is of aid in the differentiating the two diseases. 



DISEASES OF THE PERICARDIUM 



250 



Chronic Adhesive Pericarditis 

Pathology. — Tn chronic adhesive pericarditis adhesions are left 

as the result of a previous acute pericarditis of the fibrinous or sero- 
fibrinous type. The adhesions may be localized to a limited ex- 
tent of the visceral and parietal membranes or may be universally 
distributed over these membranes. The adhesions, moreover, 
may exist between the external surface of the pericardium and 
the adjacent pleura, constituting pleuro-pericarditis or medias- 
tino-pericarditis. 

The internal form of chronic adhesive pericarditis, in which 
the adhesions exist between the visceral and parietal layers often 




Fig. 132. — Pericardial adhesions. (From Delafield and Prudden.) 

does not embarrass the cardiac action, and often gives rise to no 
symptoms and few physical signs. But if the adhesions are 
abundant there is more or less embarrassment of the cardiac ac- 
tion, with consequent hypertrophy and dilatation of that organ. 

In external pericarditis the adhesions bind the outer surface 
of the pericardial sac to the costal pleura anteriorly or to the dia- 
phragm, or the esophagus, or the spinal column, or the great 
vessels arising from the base of the heart. In this form the ac- 
tion of the heart often causes systolic retractions of the thoracic 
parietes. 

As stated, the condition of the myocardium depends upon the 
degree of interference with the heart's action. The heart is 



260 PHYSICAL DIAGNOSIS 

often unchanged in simple adhesions within the pericardial sac; 
but shows hypertrophy and dilatation in extensive adhesions. 

Physical Signs. — Inspection. — With cardiac hypertrophy there 
may be undue prominence of the precordia with the apex beat 
displaced from its normal site in the fifth left interspace. There is 
often a systolic retraction of the chest wall anteriorly near the 
apical area. In cases with diaphragmatic adhesions there is often 
a systolic retraction of the tenth and eleventh interspaces pos- 
teriorly below the left scapula (Broadbent's sign). 

Friedreich's sign, diastolic collapse of the jugular veins may be 
noted in some cases; and Kussmaul's sign, inspiratory overful- 
ness of the jugulars is sometimes to be noted. The mobility of 
the diaphragm is often interfered with and limited in extent by 
adhesions. 

The cardiac impulse may be wavy and increased very much in 
extent. Upon changing the patient's position, laying him on his 
side, the apex beat or cardiac impulse often does not move with 
this change of posture as it normally does. 

Palpation. — "There may be a diastolic shock, a sudden re- 
bound of the heart walls during diastole, after having been 
drawn together during systole against the resistance of the ad- 
hesions." (Butler.) The pulsus paradoxus is often present. 
Palpation confirms displacement of the apex beat when this is 
present. Adhesions between the pericardium and diaphragm 
often prevent the normal epigastric excursion during inspiration. 

Percussion. — Percussion reveals a considerable increase in the 
transverse diameter of the heart. But this is not a constant find- 
ing, as the heart may be neither hypertrophied nor dilated. 
There are often adhesions existing between the pleura and the 
pericardium so that the border of the cardiac dullness above and 
to the left of the heart is not diminished by full inspiration, as 
the anterior border of the left lung, is prevented from interven- 
ing between the pericardium and the anterior chest wall. But 
this too is not a constant or reliable sign. The gastric tympany 
of Traube's semilunar space is often encroached upon. 

Auscultation. — The character of the heart sounds depends upon 
the state of the myocardium. If the heart is hypertrophied, they 
are accentuated; whereas, if cardiac dilatation has supervened, 
they are diminished. There may be present the murmurs of co- 
existing valvular disease, not dependent upon the condition itself. 
A friction rub may rarely be heard along the left border of the 



DISEASES OF THE PERICARDIUM 261 

sternum. The pulmonic second sound is sometimes reduplicated, 
and sometimes there is a systolic murmur at the mitral area. 

Diagnosis. — AYith a history of pericarditis, the finding of 
signs of adhesion such as fixation of the eardiac impulse, over- 
fulness of the cervical veins during inspiration, and diastolic 
collapse of these vessels, with systolic retractions of the thoracic 
walls anteriorly or Broadbent's sign posteriorly, point to chronic 
adhesive pericarditis. It is true that a systolic retraction of the 
thoracic wall in the region of the apex may be due to atmos- 
pheric pressure, in cases of hypertrophy of the heart, when the 
anterior borders of the Lungs are tardy in closing in between the 
heart and anterior chest wall, but the systolic retraction of chronic 
adhesive pericarditis is altogether more forcible than is this 
phenomenon. 

In cases where there are only a lew simple adhesions between 
the epicardium and visceral pericardium, causing little or no 
embarrassment to the action of the heart, a diagnosis is extremely 
difficult or impossible. 

HYDRO-PERICARDIUM (HYDROPS PERICARDII) 

Hydro-pericardium, the accumulation of serous fluid in the 
pericardial sac, is usually a sequence of the general dropsy of 
nephritis, or of valvular heart disease, more rarely being due 
to thrombosis of the eardiac veins. The pericardial sac contains 
a variable amount of clear, serous fluid. 

The physical signs are those of fluid in the pericardial sac. 
There is, however, no friction rub, pain, or fever, which excludes 
pericarditis with effusion. Coupled with a history of cardiac or 
renal disease, these signs are suggestive. The condition is often 
overlooked entirely. 

Hydro-pericardium produces dyspnea by compression of the 
lungs. 

HEMO-PERICARDIUM 

This is the presence of blood or blood-tinged fluid in the peri- 
cardial sac. The fluid of sero-fibrinous pericarditis is sometimes 
tinged with blood. It also follows stab wounds or penetrating 
wounds from other causes. It may be due to rupture of the 
ascending part of the aorta before it leaves the pericardial sac, 
or it may be due to rupture of a coronary artery. 

The physical signs are those of fluid in the pericardial sac, 



262 



PHYSICAL DIAGNOSIS 



with in some cases signs of internal hemorrhage, as pallor, rapid 
weak pulse, dyspnea and collapse. Death occurs early as a re- 
sult of pressure upon the heart. 



PNEUMOPERICARDIUM 

Pneumo-pericardium, the presence of gas in the pericardial sac' 
is usually associated with the presence of fluid (hydr ©-pneumo- 
pericardium), blood (hemo-pneumo-pericardium), or pus (pyo- 



■ ■ 



r 



:% 



, ; :r 



f m 






>cr 




Fig. 133. — Malignant endocarditis of aortic valve. (From McFarland.) 

pneumo-pericardium). It is a disease which is only rarely en- 
countered. 

Pneumo-pericardium may be the result of penetrating wounds ; 
perforation of the pericardium by a tuberculous cavity, gangrene 
of the lung or pneumo-thorax ; or it may be spontaneous, owing 
to the development of the bacillus aerogenes capsulatus of Welch. 
Malignant disease of the esophagus or stomach rarely causes 
perforation of the pericardium and pneumo-pericardium. 

Physical Signs. — Upon inspection there may be precordial bulg- 
ing with absence of the visible apex beat. Upon palpation a fric- 



DISEASES OF THE PERICARDIUM 263 

tion rub can sometimes be felt, and in other cases associated with 
fluid succussion fremitus. Upon percussion the normal area of 
cardiac dullness will yield hyper-resonance, while the level of 
the fluid in the pericardial sac will give dullness. 

Upon auscultation the heart sounds are feeble being obscured 
by the pericardial succussion sound, which is a churning sound 
which has been likened to the sound produced by a water-wheel in 
motion. A friction sound may often be heard. The succussion 
sound is distinctive and pathognomonic. 

Diagnosis. — The succussion sound of the condition is pathog- 
nomonic and when demonstrated makes the diagnosis clear. 
Pneumo-pericardiuni may be confused with left sided pneumo- 
thorax or gaseous distention of the stomach. In left pneumo- 
thorax the area of cardiac dullness is not obliterated, and the 
cardiac impulse is usually visible though often displaced toward 
the opposite side of the chest. The same principle applies to dis- 
tention of the stomach; and, moreover, the tympanitic note of a 
distended stomach disappears when a stomach tube is passed and 
the gas is liberated from the viscus. 



CHAPTER XVIII 
DISEASES OF THE ENDOCARDIUM AND VALVES 

ACUTE ENDOCARDITIS 

Pathology. — Acute endocarditis occurs in two forms, simple 
acute endocarditis, and malignant or infective endocarditis. 

Acute simple endocarditis is nearly always secondary to dis- 
ease elsewhere in the bodily economy. Probably the most fre- 
quent cause is rheumatism or acute rheumatic fever. Next in fre- 
quency comes tonsillitis, followed by scarlatina, and chorea. 
Many acute infections are liable to3,become complicated with 
acute endocarditis. Wasting diseases, as carcinoma, diabetes and 
nephritis, are frequently associated with acute endocarditis. 

Recurrent endocarditis is a form of endocarditis in which 
valves which are the site of chronic lesions suddenly light up 
with acute attacks of endocarditis. Endocarditis occurs in as- 
sociation with the exanthematous fevers occasionally and is a 
not infrequent complication of erysipelas. 

Acute endocarditis occurs more frequently in males than in 
females, and is most frequent about the third and fourth decades. 

Simple endocarditis often develops during the course of tuber- 
culosis or gout. 

The lesions of acute simple endocarditis very rarely affect the 
endocardium lining the walls of the chambers of the heart (mural 
endocarditis) ; but this number of cases is so small as to be neg- 
ligible. In the vast majority of cases the changes are in the valves 
themselves (valvular endocarditis). 

The earliest changes from normal in the valves is noted at a 
point a little distance from the free edge, the point where 
the valves come into contact. It is probable that the earliest 
changes are a decrease in the size of the individual endothelial 
cells with a tendency to assume a cuboidal form, leaving crevices 
between the cells by way of which bacteria circulating in the blood 
are enabled to penetrate and affect the deeper structure of the 
valve. 

In the simplest type of change there is necrosis of the valvular 

264 



DISEASES OF ENDOCARDIUM AND VALVES 



265 



tissue where the bacteria penetrate, and beyond this hyaline change 

in the valvular tissue. 

Fibrin is deposited upon the denuded area layer after layer, 
forming excrescences. This constitutes the verrucose type of sim- 
ple endocarditis. If these verrucosities are torn loose by the cir- 
culating blood they float free in the blood stream as emboli. In 
course of time the excrescences become organized and scar tissue 
replaces the verrucose excrescence, which by contracting causes 
deformity of the valve and incompetency. 




Fig. 134. — Endocarditis, verrucose form. (From Delalield and Prudden.) 



Malignant or infective endocarditis occurs in rare instances as 
a primary inflammation of the endocardium. Usually it is sec- 
ondary to puerperal sepsis, osteo-myelitis, rheumatic fever, or as 
a progression of the simple acute form into the malignant. It 
may be secondary to erysipelas or gonorrhea. Malignant endo- 
carditis is often engrafted upon valves the seat of chronic endo- 
carditis. 

In this form of endocarditis purulent collections form in the 
connective tissue stroma of the valve, the vessels dilate and new 



266 PHYSICAL DIAGNOSIS 

vessels grow out into the valve stroma. There is an attempt at 
repair by connective tissue formation, but the diseased surface 
of the valve does not heal with a smooth surface, but with ir- 
regular villous processes consisting of granulation tissue and 
fibrin. Perforation of a valve often occurs and the new connec- 
tive tissue always leaves the valves incompetent. Emboli formed 
of fragments of the diseased villous processes on the valves may 
be carried to remote organs, and, being infectious, cause meta- 
static abscesses. (See Fig. 133, p. 262.) 

Physical Signs. — Inspection. — In simple acute endocarditis in- 
spection usually reveals nothing. In malignant endocarditis if 
dilatation has supervened the apex beat is weak and diffuse and 
perhaps displaced. The signs upon inspection in both forms are 
few. 

Palpation. — Palpation yields little or no information in -both 
forms. If valvular lesions are present there may be a palpable 
thrill ; and if dilatation is present the apex beat may be feeble 
and slapping and displaced from its normal position. 

Percussion. — Percussion will add no information in acute simple 
endocarditis. In the malignant form the percussion findings are 
similarly lacking unless dilatation is imminent or has supervened, 
when there will be increase in the area of cardiac dullness in one 
or more directions. 

Auscultation. — In simple acute endocarditis there is often a 
systolic murmur over the apex or at the aortic area ; but these are 
not pathognomonic as they might arise as a result of anemia or 
valvular lesion of other causation. In the malignant form mur- 
murs of pre-existing valvular disease are often present. If it is 
possible to detect changes in the quality of these murmurs in daily 
examinations, an acute endocarditis maj^ be indicated as being en- 
grafted upon a previous valvular lesion. 

Diagnosis. — In the diagnosis of acute simple endocarditis the 
history is very important. A history of rheumatic fever, ton- 
sillitis, or an acute infectious disease coupled with the meager 
physical findings may suggest a diagnosis. Of the physical 
signs the most important probably is a systolic murmur at the 
mitral area, particularly if this develops upon a roughened some- 
what prolonged first sound. Of course, these murmurs must be 
distinguished from a murmur due to anemia or a pre-existing 
valvular lesion. But murmurs of anemia are more prone to in- 
volve the pulmonic valve and very rarely indeed do they involve 
the aortic valve, over which in endocarditis a murmur may some- 



DISEASES OF ENDOCARDIUM AND VALVES 267 

times be audible. It is difficult or impossible to differentiate an 
acute simple endocarditis supervening upon a chronic valvular 
lesion, as the difference in the murmur is slight if any. 

The diagnosis of malignant endocarditis when there is a history 
of previous septic infection and evidences of metastatic involve- 
ment in other parts of the body is fairly easy. Regurgitant dia- 
stolic murmurs are suggestive in a measure, as functional mur- 
murs are mostly systolic in time. There is leukocytosis and pre- 
cordial distress and fever of a septic type. It should be remem- 
bered that malignant endocarditis presents a very varied symp- 
tomatology, sometimes occurring in a cardiac type in which the 
murmurs of chronic valvular lesions predominate the picture; 
in a pyemic type with symptoms of metastatic involvement; in a 
typhoid type closely simulating typhoid fever; and finally a type 
in which cerebral symptoms predominate, as delirium or coma. 

From typhoid fever it is differentiated by the more abrupt 
onset of endocarditis, the absence of the step-ladder ascent of 
the fever in the first week, and the presence of precordial dis- 
tress and dyspnea early in endocarditis, with chills and leuko- 
cytosis in marked contrast to the leukopenia of typhoid fever. 

CHRONIC ENDOCARDITIS 

Pathology. — Chronic endocarditis is usually secondary to acute 
endocarditis, particularly to that form occurring in association 
with acute rheumatic fever and tonsillitis. Other cases of chronic 
endocarditis arise in persons who have not previously had acute 
endocarditis, as a result of the constant circulation in the blood 
of the toxins of lead, alcohol, syphilis, gout, and diabetes. Ex- 
cessive and prolonged muscular exertion in laborious occupations 
may initiate the sclerotic process in the aortic valve segments. 
These patients also present sclerosis of the arteries, of which the 
sclerosis of the valves is merely a part. Arterio-sclerosis and 
nephritis by raising blood pressure tend to cause sclerosis of the 
aortic valves. 

The changes in the valves consist of a progressive sclerosis 
with ultimate deposition of calcium salts. The valves are thick- 
ened, inelastic, and their edges often coalesce. This produces a 
permanent condition of incompetency or stenosis. Moreover, the 
chorda? tendinea? are shortened and thickened so that they no 
longer permit of close co-aptation of the edges of the valve seg- 
ments. The ventricles hypertrophy to compensate for the val- 



268 



PHYSICAL DIAGNOSIS 




Fig. 135. — Chronic endocarditis. (Delafield and Prudden.) 



vular deficiency; and ultimately degeneration of the myocardium 
and dilatation supervene. 

The Physical Signs of chronic endocarditis are those of chronic 
valvular disease, varying in their manifestations and results 
with the valve affected or valves affected, if more than one, as is 
often the case. 

CHRONIC VALVULAR DISEASE 

Chronic valvular lesions of the heart are of two types: stenotic, 
produced by narrowing or partial obstruction offered at the val- 
vular orifice to the onward flow of the blood; and regurgitant, 
produced by the inability of the valve cusps to prevent the back- 
ward flow of the blood, owing to deformity of the valve cusps 
or to a temporary stretching of the valvular orifice so that the 
normal segments are incapable of closing the abnormally large 
orifice. Not infrequently a lesion of a valve which produces 
stenosis also results in regurgitation, incompetence, or insuf- 
ficiency. 



DISEASES OF ENDOCARDIUM AND VALVES 269 

The valves of the left side of the heart are much more fre- 
quently the sites of chronic lesions than are those of the right 
side. Acquired lesions of the valves of the right side of the 
heart are very rare, the vast majority of lesions on this side de- 
pending upon congenital malformations. However, acquired 
lesions do occur in this portion of the valvular mechanism of 
the heart, usually as the end result of left sided Valvular lesions. 
Generaly speaking, mitral lesions are more frequent than are any 
other valvular lesions; aortic lesions coming second in fre- 
quency, while lesions of the valves on the right side are very 
rare. 

Effects of Valvular Lesions. — The immediate effect of a val- 
vular lesion is to decrease the amount of Mood in front of the 




Fig. 136. — Fenestration of semilunar valves. (From Delafield and Prudden.) 

lesion and to increase the amount of blood behind the lesion; 
hence, to lower the blood pressure in the arterial system and to 
raise the blood pressure in the venous system. This is well il- 
lustrated by the sequence of events following aortic stenosis. 
The first result of a stenotic lesion at this orifice is to produce 
dilatation of the left ventricle, the ventricle being unable to ex- 
pel its increased blood content. The ventricle then hypertrophies 
in response to the increased demand for work. So long as this 
hypertrophy is maintained, or so long as compensation is not 
broken, no change is noted in the general circulation. But the 
time conies when the ventricle is unable to sustain the extra bur- 
den and dilatation of the left ventricle gradually supervenes. 
The dilatation of the left ventricle, affecting the mitral ring 



270 PHYSICAL DIAGNOSIS 

permits stretching of this ring, the cusps of the valves are unable 
to properly close the orifice, with the result that a certain amount 
of blood regurgitates into the auricle during ventricular systole. 
This extra load thrown upon the left auricle produces dilatation 
of the left auricle, which in turn hypertrophies to compensate 
for the regurgitation. This hypertrophy in course of time yields 
to dilatation ; when, by virtue of the regurgitation of blood from 
the left ventricle which the dilated auricle is unable to expel dur- 
ing its systole, the blood pressure in the pulmonary circulation is 
raised, as evidenced by accentuation of the pulmonic second sound. 

The continuous high tension in the pulmonary circuit leads to 
engorgement of the pulmonary venous system, resulting in edema 
of the lung, with bronchitic symptoms, or in more extreme grades, 
to hydro-thorax. 

The increased strain which is thrown upon the right ventricle 
by the accumulation of blood in the lesser circulation produces 
dilatation of the right ventricle, which hypertrophies for a time 
to compensate for the extra burden, and then dilates. This 
dilatation of the right ventricle produces enlargement of the 
right auriculo-ventricular ring, which the segments of the tri- 
cuspid valve are unable to close. Hence the right auricle goes 
through the same cycle of dilatation, temporary hypertrophy 
and permanent dilatation, producing a permanent tricuspid re- 
gurgitation with systolic pulsation of the liver, and general venous 
stasis with edema of the lower extremities, ascites, or general 
anasarca. 

AORTIC INSUFFICIENCY (CORRIGAN'S DISEASE) 

Pathology. — Aortic insufficiency, aortic incompetency, aortic 
regurgitation, or Corrigan's disease may result from pathologic 
alteration of the valves due to endocarditis, whether shrinkage 
of the cusps, adhesions between the cusps, or perforation of one 
or more cusps ; dilatation of the aortic ring in syphilitic aortitis ; 
enlargement of the aortic ring due to aneurism of the root of the 
aorta, or dilatation of the heart; or congenital defects in the 
valves, as absence of a cusp or fenestration of the cusps. 

The valves, deformed from any of the above mentioned causes, 
are unable to prevent the reflux of blood from the aorta into 
the ventricle during diastole, hence the left ventricle becomes the 
target for this reflux which produces a murmur as it passes back- 
ward through the incompetent valves. The left ventricle, 
in response to the increased demand for work in expelling 



DISEASES OF ENDOCARDIUM AND VALVES 



271 



a greater quantity of blood at each systole hypertrophies and 
compensates for the valvular deficiency. This hypertrophy be- 
comes very great, constituting the Cor Bovinum. After this 
compensation has been maintained for a variable time, the ven- 
tricle dilates and stretching of the mitral ring permits a regurgi- 
tant lesion at this site. This leads to heightening of the blood 
pressure in the pulmonary circulation and to accentuation of the 
pulmonic second sound and hypertrophy of the right ventricle. 
Physical Signs. — Inspection. — In women and children, in whom 




/ ', 













Fig. 137. — Chronic \errucose endocarditis of aortic valves. (From McFarland.) 

the chest Avail is elastic, there is apt to be a certain degree of 
precordial bulging. The apex beat is displaced downward and 
toward the left owing to the left ventricular hypertrophy. The 
capillary pulse of Quincke is present. There is dyspnea, some- 
times orthopnea and cyanosis when the heart is beginning to 
fail. The carotid arteries may pulsate and there is apt to be sys- 
tolic epigastric pulsation. The area of the cardiac impulse is 
increased and it is displaced sometimes as low as the seventh in- 
terspace and as far outward as the anterior axillary line. 
Palpation. — The impulse during cardiac or left ventricular hy- 



272 PHYSICAL DIAGNOSIS 

pertropliy is firm and forcible and heaving ; and later, when dilata- 
tion is imminent is weaker and more slapping. A diastolic thrill 
is often present at the aortic valve area or over the middle of the 
gladiolus. 

The pulse is of the water-hammer or Corrigan type. 

Percussion. — The area of cardiac dullness is increased in extent, 
mainly downward and toward the left. In rare cases the dullness 
is increased to the right of the sternum. Aortic incompetence pro- 
duces greater increase in the area of cardiac dullness than does any 
other valvular lesion. 

Auscultation. — There is a diastolic murmur with its point of 
maximum intensity at the aortic valve area near the junction of 
the second right costal cartilage with the sternum, or over the 
middle of the gladiolus or in the neighborhood of the apex of 
the heart. The point of maximum intensity of this particular 
murmur is thus very variable. Perhaps in the greatest majority 
of cases it is near the middle of the gladiolus. The line of 
transmission is downward and, toward the left. The murmur 
may and usually does replace the second sound of the heart at 
the aortic area; but sometimes both murmur and second sound 
can be heard. (See Fig. 116, p. 235.) 

The quality of the murmur is blowing and not unmusical. The 
pulmonic second sound is unaltered, unless there is, as is fre- 
quently the case, an associated regurgitant lesion at the mitral 
area, in which event the pulmonic second sound is accentuated. 
The first sound of the heart is unusually loud and somewhat pro- 
longed, owing to the large volume of blood to be expelled at each 
systole of the left ventricle. If there is an associated mitral re- 
gurgitation the first sound at the apex will be replaced by a sys- 
tolic murmur. 

A diastolic murmur at the apex in Corrigan 's disease has been 
described by Austin Flint, the mechanism of which has been 
explained in a previous section. A diastolic murmur is often 
audible upon auscultation over the carotid artery; and Duroziez's 
sign, which has been described, is often demonstrable over the 
femoral artery. 

Diagnosis. — The diagnosis of aortic regurgitation is as a rule 
not difficult. The diastolic murmur at the aortic area, trans- 
mitted downward and toward the left axilla, the signs of hyper- 
trophy or dilatation of the left ventricle, the pulsations in the 
carotids, the water-hammer pulse, and Duroziez's sign, when 
present, make the diagnosis. 



DISEASES OF ENDOCARDIUM AND VALVES 



273 



AORTIC STENOSIS 

Pathology. — True organic stenosis of the aortic valve is en- 
countered but rarely; but roughening of the valve segments or 
of the aortic lining just beyond the valve, generating a murmur 
very similar to that caused by aortic stenosis is rather frequent. 




Fig. 138. — Chronic endocarditis with coalescence of two aortic cusps. 

and Prudden.) 



(From Delafield 



Again, a relative stenosis of the aortic valve may be present 
arising as the result of dilatation of the aorta distal to the valve. 
a state which also produces a murmur simulating the murmur of 
organic aortic stenosis. 

Stenosis of the aortic valve arises as a result of endocarditis, 
which leads to adhesion of the valvular cusps, associated with 
or followed by fibrosis and calcification of the valve leaflets. In 



274 PHYSICAL DIAGNOSIS 

other instances aortic stenosis is part of a general arteriosclero- 
sis, which extends to and involves the valve segments. 

Congenital deformity of the valve, there being merely a but- 
ton-hole slit in a solid membrane instead of the three valvular 
cusps, is an infrequent cause of aortic stenosis. 

In elderly persons aortic stenosis is usually the result of arterio- 
sclerosis, while in children and young patients it is generally a 
sequence of rheumatic endocarditis attacking the aortic valve 
along with other cardiac valves. 

Whatever the cause of obstruction, the effect upon the my- 
ocardium is in each case very much the same. An increased load 
is thrown upon the left ventricle, which hypertrophies in the 
effect to overcome the obstacle to the propulsion of its contents 
into the greater circulation. That is to say, the ventricle com- 
pensates for the valvular lesion. So long as compensation is 
adequate, so long as compensation is maintained, there are no 
signs of embarrassment of the circulation. But when the left 
ventricle begins to fail the left auriculo-ventricular ring stretches, 
the mitral valve becomes unable to close the abnormally large 
orifice, the pressure is raised in the pulmonary circulation, caus- 
ing accentuation of the pulmonic second sound and leading even- 
tually to hypertrophy of the right ventricle, with all the se- 
quence of changes detailed in the section on the results of 
valvular lesions (see page 269). 

The left ventricular hypertrophy of aortic stenosis differs from 
that of aortic regurgitation in that in the former condition the 
walls of the ventricle are thickened without any increase in th^ 
size of the ventricular chamber ; whereas in the hypertrophy of 
the latter the chamber is increased in size, a condition to which 
the term eccentric hypertrophy has been applied. 

As a rule the lesion which produces aortic stenosis also ren- 
ders the valve segments incapable of completely closing the 
orifice during diastole, so that aortic stenosis and incompetency 
not infrequently co-exist. 

Physical Signs. — Inspection. — The cardiac impulse is displaced 
to the left and downward, owing to the left ventricular hyper- 
trophy. As cardiac dilatation supervenes the lateral displace- 
ment increases. The impulse is of increased extent ; and its char- 
acter is strong and heaving so long as compensation is main- 
tained, becoming weak and indistinct when the left ventricle 
fails. The intervention of the borders of emphysematous lungs 



DISEASES OF ENDOCARDIUM AND VALVES 2 i 5 

between the heart and chest wall in elderly patients tends to mask 
the character of the cardiac impulse or to obscure it entirely. 

Palpation. — A systolic thrill is nearly always demonstrable at 
the aortic valve area. As stated, the cardiac impulse may be 
strong and heaving or weak and indistinctly palpable, its char- 
acter varying with the state of the myocardium. 

The pulse is slow and small, particularly in marked organic 
stenosis. Jt is regular as long as compensation is maintained ; later 
showing signs of cardiac dilatation. 

Percussion. — The transverse dullness of the heart is increased to 
a variable extent. This increase, however, particularly in elderly 
patients, may be masked by ari emphysematous condition of the 
lungs. 

Auscultation. — There is a systolic murmur at the aortic area. 
The murmur is usually harsh, sometimes musical, well sustained. 
It is transmitted into the greal cervical vessels. Quite frequently 
there is a double murmur at the aortic area, systolic and dia- 
stolic, for the reason that the lesion which causes stenosis also 
permits regurgitation of blood into the ventricle during diastole. 
The aortic second sound is rarely audible. The systolic murmur 
of relative mitral insufficiency is audible at the apex in most ad- 
vanced cases. (See Fig. 115, p. 235.) 

Diagnosis. — A systolic murmur at the aortic area, harsh in 
quality, well sustained in duration, transmitted upward into 
the cervical vessels, and accompanied by a thrill and a small 
slow pulse, is very suggestive of organic stenosis of the aortic 
valve. 

However, the mere presence of a systolic murmur at this 
area is not conclusive, as such a murmur may have a different 
origin. 

The murmur generated by aortic roughening is systolic in time 
and heard at the aortic valve area ; but it produces no change in 
the character of the pulse, is not accompanied by a thrill, and is not 
characterized by ventricular hypertrophy. 

Similarly, the murmur of relative aortic stenosis which is caused 
by dilatation of the aorta just distal to the valve, is systolic in 
time, but produces no alteraton in the pulse, and no organic 
change in the myocardium. 

Moreover, in both these murmurs the aortic second sound is 
unimpaired. 

Functional murmurs are rarely audible at the aortic area. They 



276 PHYSICAL DIAGNOSIS 

are musical, are transient, are not transmitted beyond the pre- 
cordia, are usually encountered in young persons, or in the anemic. 

MITRAL INSUFFICIENCY 

Pathology. — Mitral insufficiency is due to shrinking and scle- 
rosis of valve segments and chordae tendineae, the sequence of 
acute or chronic endocarditis, of rheumatic origin, or a part and par- 
cel of arterio-sclerosis. Also in left ventricular dilatation the mitral 
ring is stretched and is unable to permanently and completely 
close the left auriculo-ventricular orifice, resulting in relative 
insufficiency. 

The results upon the heart and circulation of mitral insuffi- 
ciency are as follows. During ventricular systole the mitral seg- 
ments are unable to withstand the backflow of blood, a portion 
of which regurgitates into the left auricle. Here it combines 
with the blood entering the left auricle from the great veins, 
leading to dilatation of the left auricle, and eventually to hyper- 
trophy. The pressure is thus raised in the lesser or pulmonary 
circulation with resulting hypertrophy of the right ventricle. The 
left ventricle hypertrophies owing to the lack of the valvu- 
lar action of the mitral valve. More or less edema and congestion 
of the lungs occurs leading to symptoms of catarrhal inflammation 
of the bronchial tubes. In course of time the tricuspid valve de- 
velops a "safety-valve" leak and there is more or less extensive 
venous engorgement of the general circulation. 

Physical Signs. — Inspection. — The cardiac impulse is displaced 
downward and toward the left, owing to the associated left ven- 
tricular hypertrophy. The character of the impulse varies with 
the state of the myocardium. In hypertrophy it is strong and 
forcible ; in cardiac dilatation it is weak, slapping, and undulatory. 
Pulsations are often visible in the veins of the neck. The cardiac 
impulse may be displaced far to the left, sometimes past the 
left nipple line, sometimes as far as the anterior axillary 
line. In children and thin chested women, a moderate degree 
of precordial bulging not uncommonly attends the condition. In 
these cases there is commonly a wide area of impulse. Systolic 
pulsation in the epigastrium is often present in cases associated 
with right ventricular hypertrophy. Pulsation over the liver, when 
present, signifies tricuspid regurgitation. 

Palpation. — A systolic thrill over the apex is rarely present. 



DISEASES OF ENDOCARDIUM AND VALVES 277 

The impulse is strong and heaving so long as hypertrophy is main- 
tained, to become weak and uneven when this is lost. 

The pulse is normal or regular in rate and rhythm and of full 
volume as long as compensation is maintained. Later when cardiac 
failure is imminent it is irregular in force and rhythm. Not every 
ventricular contraction may produce a radial pulse. 

Percussion. — The transverse dullness of the heart is increased 
to the left and slightly downward. In cases associated with right 
ventricular hypertrophy the cardiac dullness often extends well 
to the right of the sternum. 

Auscultation. — Auscultation over the apex reveals a systolic mur- 
mur, with its point of maximum intensity located over the apex, 
and transmitted toward the left axilla, or even as far as the 
angle of the left scapula. The murmur is blowing and rather 
musical, partially or totally obscuring the firsl sound at the 
apex. The murmur varies in intensity with changes of posture. 
Thus, it may be absent in the recumbent, and audible in the 
erect posture. When present it is well broughl oul by muscular 
exertion. The pulmonic second sound is accentuated, or there 
may be a systolic tricuspid safety-valve leak. The aortic sec- 
ond sound is also accentuated due to hypertrophy of the left 
ventricle. Often this accentuated sound is clearly audible over 
the apex during diastole. (See Fig. 114, p. 233.) 

Diagnosis. — The diagnosis of mitral insufficiency rarely presents 
any great difficulty. The presence of a systolic murmur at the 
apex, which is blowing and musical, transmitted toward the left 
axilla, associated with accentuation of the pulmonic second sound, 
and often of the aortic second as well, make a clear picture. 

A functional murmur sometimes occurs at the mitral valve, 
though they are more frequent at the pulmonic valve. But still 
the mitral valve is the second place in frequency for these mur- 
murs. But, as noted previously, these murmurs do not produce 
ventricular hypertrophy, nor are they propagated beyond the 
precordia, and usually occur in the anemic and debilitated. 
Moreover, functional murmurs are transient. 

MITRAL STENOSIS 

Pathology. — Stenosis of the mitral valve is usually a sequence 
of acute endocarditis arising during the course of rheumatism, 
tonsillitis, scarlatina, chorea, or other acute infectious disease. 
But there is another group of cases in which a slow sclerosis of 



278 PHYSICAL DIAGNOSIS 

the cusps of the valve occurs without any history of infective 
disease. 

As in other stenotic lesions, the valve cusps are sclerosed and 
shrunken, the edges often adherent, sometimes leaving a me,re 
slit or chink, the "button-hole" orifice of Corrigan. In the 
slowly sclerotic cases the valves are seldom found adherent, but 
there is considerable thickening and shortening of the chordae 
tendineae, preventing proper co-aptation of the valve segment 
edges. In yet other cases segmental deformity is absent, but the 
ring is rendered smaller by the projection of calcareous masses 
from the margin of the ring, or as a result of congenital defect. 

In mitral stenosis, when compensation is maintained the myo- 
cardium of both left auricle and left ventricle is thickened. The 
ventricular hypertrophy develops as the result of the aspirating 
action of this chamber in drawing its proper amount of blood 
through the narrowed orifice and because it must contract pow- 
erfully upon the smaller amount of blood to force it into the 
aorta. The auricular hypertrophy develops with the efforts of 
the auricle to expel its increased contents through a narrowed 
orifice. 

Physical Signs. — Inspection. — In thin chested patients and in 
young children there is visible bulging of the lower and right por- 
tions of the precordia the result of right ventricular hypertrophy. 
The cardiac impulse is strong, but its area is diminished. It is 
displaced to the left, but seldom downward. Systolic pulsation of 
the epigastrium is commonly seen, as the result of the powerful 
contractions of the hypertrophied right ventricle. 

Palpation. — Over the mitral valve area over the apex there is a 
pre-systolic thrill which is pathognomonic of the disease. The pul- 
monic valve shock is accentuated at the left second interspace 
near the sternum. 

The pulse is small and of low tension, re'gular during compen- 
sation, irregular when dilatation is imminent. 

Percussion reveals an increase in the transverse diameter, par- 
ticularly to the right of the sternum owing to right auricular and 
ventricular hypertrophy, and to a minor extent to the left of the 
normal cardiac outline, as a result of left ventricular hypertrophy. 

Auscultation reveals a pre-systolic murmur over the apex, 
which is not transmitted beyond the precordia. This murmur is 
harsh, ingravescent or crescendo in quality, increasing steadily in 
intensity to its termination, and is commonly followed by a snap- 
ping first sound at the apex. This murmur must be differentiated 



DISEASES OF ENDOCARDIUM AND VALVES 279 

and distinguished from the Flint murmur occurring during aortic 
regurgitation. The pulmonic second sound is accentuated, and 
occasionally a "safety-valve" systolic murmur is audible over 
the tricuspid area. The second sound of the heart at the apex is 
feeble, either from imperfect filling of the aorta by the smaller 
content of the left ventricle, or because the hypertrophied right 
ventricle intervenes between the aortic valve and the chest wall. 
(See Fig. 113, p. 232.) 

Diagnosis. — A pre-systolic murmur at the mitral area, ingra- 
vescent or crescendo in quality, followed by a snappy first sound, 
and an enfeebled second sound; an accentuation of the pulmonic 
second sound; extension of the transverse dullness of the heart; 
a pre-systolic thrill at the apical area; and the small pulse of low 
tension, suggest the diagnosis of mitral stenosis. The murmur of 
Austin Flint must be eliminated before the case is pronounced 
one of mitral stenosis. 



PULMONARY INSUFFICIENCY 

Pathology. — Pulmonary insufficiency or regurgitation is a very 
rare condition. When found, it is usually due to a congenital 
deformity of the pulmonary valve, only in rare instances being 
due to chronic endocarditis, the sequence of rheumatism or other 
form of sepsis. 

Physical Signs. — Inspection. — There is moderate precordial 
bulging chiefly to the right of the sternum or over the ensiform 
cartilage. The impulse lies behind the sternum and is invisible, 
but in some instances may be displaced to the right of this bone. 

Palpation rarely reveals a thrill over the pulmonary valve area ; 
more frequently it shows a systolic pulsation to the right of the 
sternum from the second to the sixth interspaces. The pulse is as 
a rule quite unchanged. 

Percussion shows an increase in the transverse dullness of the 
heart to the right of the sternum, with seldom any increase toward 
the left and downward. 

Auscultation reveals a diastolic murmur with its point of maxi- 
mum intensity at the pulmonary area, transmitted downward along 
the left border of the sternum. The murmur is blowing and not 
unmusical. It masks or replaces the second sound of the heart at 
the pulmonary area. (See Fig. 120, p. 237.) 

Diagnosis. — The diagnosis rests upon the physical signs de- 
scribed; but it must be borne in mind that while murmurs are 



280 PHYSICAL DIAGNOSIS 

frequently audible at the pulmonary area, they are usually func- 
tional and systolic. Functional murmurs must be excluded. 

PULMONARY STENOSIS 

Pathology. — Stenosis at the pulmonary valve is nearly always 
due to a congenital defect. Very rarely the lesion is the se- 
quence of ulcerative endocarditis attacking the pulmonary valve. 

Physical Signs. — Inspection. — The precordia in children and 
thin chested individuals is apt to bulge, the cardiac impulse is 
diffuse and feeble, and there is often a systolic pulsation to the 
right of the sternum. 

Palpation reveals usually a systolic thrill at the pulmonary area. 
The pulse is unaltered. (See Fig. 94, p. 203.) 

Percussion reveals an increase in the transverse dullness of the 
heart to the right of the sternum, with little or no increase to the 
left and upward. 

Auscultation. — A systolic murmur is audible at the pulmonary 
area, which is transmitted upward into the great vessels of the 
neck. The murmur is usually harsh and unmusical. The first 
sound at the tricuspid area is often replaced by the safety-valve 
leak of tricuspid insufficiency. Occasionally a double murmur, 
systolic and diastolic is audible at the pulmonary area, due to a 
lesion which produces both stenosis and insufficiency. 

Diagnosis. — The physical signs described when encountered in 
a patient who is not the subject of valvular disease of the left 
side of the heart, suggests the probability of a true and isolated 
pulmonary lesion. (See Fig. 119, p. 237.) 

TRICUSPID INSUFFICIENCY 

Pathology. — Tricuspid insufficiency occurs very rarely as a re- 
sult of congenital lesions of the valve, the vast majority of the 
cases being instances of relative insufficiency due to lesions of the 
left side of the heart. The relative insufficiency results from 
increased tension in the pulmonary circuit, usually produced by 
regurgitant lesions of the left heart ; though a similar condition 
may arise as the result of heightening of the pressure in the 
pulmonary circulation by obstruction to the flow of blood of- 
fered by obstructive pulmonary lesions, as emphysema and tu- 
berculosis. 

Physical Signs. — Inspection, — Systolic jugular pulsation is a 



DISEASES OF ENDOCARDIUM AND VALVES 281 

very reliable sign of tricuspid insufficiency, as is also a systolic 
pulsation of the liver. The cardiac impulse is rather diffuse and 
its intensity is decreased. 

Palpation shows the weak apical impulse, and bi-manual pal- 
pation detects a hepatic systolic pulsation and differentiates it from 
the transmitted impact of a hypertrophied right ventricle. The 
pulse is weak, but regular. 

Percussion shows extension of the area of cardiac dullness to the 
right caused by right auricular and ventricular hypertrophy or 
dilatation; and not infrequently an associated increase in the 
transverse diameter to the left, owing to hypertrophy or dilata- 
tion of the left ventricle associated Avith the left sided valvular 
lesion w r hich has resulted in the relative lesion at the tricuspid 
orifice. 

Auscultation reveals a sj^stolic murmur over the tricuspid area 
at the lower border of the sternum. The murmur is not harsh 
and is transmitted upward and toward the left. The pulmonic 
second sound is enfeebled because of the small output of the 
right ventricle during systole. There may be associated left 
sided valvular lesions which were responsible for the tricuspid 
lesions. (See Fig. 118, p. 236.) 

Diagnosis. — The presence of the systolic murmur at the tri- 
cuspid area, the extension of cardiac dullness to the right, the 
weakened pulmonic second sound, and often signs of left sided 
valvular lesions, make the diagnosis not difficult, particularly 
in the presence of sj^stolic jugular pulsations and hepatic pul- 
sation. 

TRICUSPID STENOSIS 

Pathology. — Tricuspid stenosis is a very rare lesion, which is 
very seldom diagnosed during life. It is usually due to con- 
genital narrowing or stenosis of the valve. 

Physical Signs. — If there are any physical signs, there will be 
a palpable thrill at the tricuspid area, pre-systolic in time. The 
patients are commonly dyspneic and cyanotic; there is a pre- 
systolic murmur at the tricuspid area, which is not transmitted 
thence; while there is extension of the area of cardiac dullness to 
the right of the sternum. (See Fig. 117, p. 236.) 



CHAPTER XIX 

DISEASES OF THE MYOCARDIUM 

ACUTE MYOCARDITIS (ACUTE MYOCARDIAL DEGENERA- 
TION) 

Pathology. — Acute myocarditis occurs clinically in two forms: 
as (1) acute parenchymatous myocarditis; (2) acute interstitial 
myocarditis. 

Acute parenchymatous myocarditis occurs as a complication of 
acute infectious febrile diseases, notably pneumonia, typhus and 
typhoid fevers, scarlatina, and diphtheria. An acute myocarditis 
arising during these diseases usually has its inception during the 
active febrile stage of the disease at which time it may be the 
cause of sudden death ; but in other instances its incidence is de- 
ferred, the condition developing and sometimes causing death 
during late convalescence. Acute parenchymatous myocarditis 
also occurs as a complication of endocarditis and pericarditis, 
but not by direct extension of the inflammatory process to the 
myocardium. 

While the name myocarditis implies an inflammation, the signs 
of acute inflammation are not in evidence, the characteristic 
changes in the myocardium being those of a slow degeneration 
or metamorphosis, ranging in severity from cloudy swelling in 
the favorable cases to fatty degeneration in the grave cases. 

Grossly the heart presents a varied picture, being pale or 
grayish-red in the presence of cloudy swelling ; yellowish in fatty 
degeneration, and gray in hyaline degeneration. It is probable 
that the earliest retrogressive change in acute parenchymatous 
myocarditis, in those cases which yield the best prognosis, is 
cloudy swelling; and that the ultimate change is a fatty degen- 
eration, in which the prognosis is extremely grave. 

Acute Interstitial Myocarditis also develops during the course 
of acute fevers, Leyden first describing the disease in connection 
with scarlatina. Rhomberg has noted the changes characteristic 
of the disease in diphtheria, typhoid fever, acute rheumatic fever, 
and variola. The disease occurs in two grades or degrees of se- 

282 



DISEASES OF THE MYOCARDIUM 283 

verity: (1) the transient nonsuppurative interstitial myocarditis; 
and (2) the more grave suppurative interstitial myocarditis. In 
the former the intermuscular spaces of the myocardium are in- 
filtrated with leukocytes, the coronary capillaries are dilated, and 
the muscle bundles present areas of vacuolation, nuclear multi- 
plication, and pigmentation; but the morbid condition often even- 
tuates in resolution without the formation of fibrous connective 
tissue between the muscle bundles. 

The suppurative form of the disease, of more grave prognostic 
significance, is usually the sequence of infectious embolism of the 
coronary arteries. When one of the terminal vessels of this 
arterial system becomes occluded by a simple, non-infectious 
embolus, anemic or hemorrhagic infarction of the myocardium is 
apt to ensue; but if the occluding embolus contains infectious 
material, if its source happens to be a vegetation from the cusp 
of a cardiac valve the seat of infective endocarditis, or an area of 
infectious osteomyelitis, a more serious lesion of the myocardium 
is produced. At the sites of obstruction circumscribed areas of 
leukocytic infiltration and bacterial colonization develop, leading 
to minute purulent infiltrations between the muscle bundles, 
weakening the heart wall and rendering rupture imminent. The 
rupture may occur externally into the pericardial sac with the 
production of a purulent pericarditis; or the pus may discharge 
into a cavity of the heart, the organisms being distributed to 
various organs of the body by the blood stream with the produc- 
tion of metastatic abscesses. 

Instead of terminating by resolution, as in the case of acute 
non-suppurative interstitial myocarditis, the areas of purulent 
infiltration result in the formation of fibrous patches, weakening 
the cardiac musculature and predisposing to aneurism of the 
cardiac wall. 

Physical Signs. — Physical signs in this disease are often lack- 
ing and when present are not clear and distinctive. The cardiac 
impulse as a rule shows a primary accentuation, with a subse- 
quent weakening in its force and area. In certain cases sudden 
death may occur either during the height of an acute infectious 
disease or even late in convalescence. A fairly reliable diagnostic 
sign is an equalization of the intensity of the first and second 
cardiac sounds, both sounds assuming a valvular quality, with 
coincident signs of pulmonary stasis. Late in the course of the 
disease, when cardiac dilatation has supervened, the area of 



284 PHYSICAL DIAGNOSIS 

cardiac dullness is extended and a relative mitral regurgitant 
murmur is commonly audible. 

Diagnosis. — The diagnosis must be reached through the dis- 
covery of a causative factor rather than upon the physical signs, 
which are often few and confusing. But when during the course 
of an acute infectious disease the heart tones become enfeebled, 
equalized, and valvular, with alterations in rhythm as embryo- 
cardia or gallop-rhythm, the incidence of an acute myocarditis 
may be suspected. 

Many cases simulate closely acute endocarditis; but in the 
latter disease the cardiac weakness is not so rapid and extreme, 
nor is the cardiac rhythm disturbed to an equal degree. 

CHRONIC MYOCARDITIS (CHRONIC FIBROUS MYOCAR- 
DITIS; CHRONIC INTERSTITIAL MYOCARDITIS) 

Pathology. — Chronic myocarditis is a sIoav sclerosis of areas 
of the myocardium, developing secondarily to changes in the 
coronary arteries. The essential lesion of the coronary circula- 
tion productive of chronic myocarditis is a narrowing or oblitera- 
tion of the lumen, the result of obliterative endarteritis or em- 
bolic occlusion. Obliterative endarteritis of the coronary cir- 
culation is merely part-and-parcel of generalized arterio-sclerosis. 

When an uninfectious embolus lodges in a terminal branch 
of a coronary artery an infarct of the myocardium is apt to form. 
The infarct is surrounded soon by a zone of infiltrating leu- 
kocytes. The infarct is wedge-shaped with the apex of the wedge 
directed toward the site of the embolism. The infarct, which may 
assume either the anemic or hemorrhagic type, leads to an area 
of softening of the myocardium, to which the term Myomalacia 
Cordis has been applied by Ziegler. This area is a point of low- 
ered resistance to the endocardiac pressure and is liable to lead 
to rupture with sudden death. If rupture does not occur, the area 
of infarction is gradually replaced by fibrous connective tissue. 

The portions of the myocardium usually attacked are usually 
the lower two-thirds of the anterior wall and the upper portion 
of the posterior wall of the left ventricle ; the interventricular 
septum ; or the bases of the papillary muscles. 

Associated changes occurring in the heart the seat of chronic 
myocarditis comprise: (1) hypertrophy; (2) dilatation; (3) val- 
vular disease. In cases of moderate involvement there is suffi- 
cient sound myocardium to compensate for the cardiac impair- 



DISEASES OF THE MYOCARDIUM 285 

ment by hypertrophy. In more extensive fibrosis, however, there 
is little intact myocardium; the cardiac wall yields under the 
normal or increased endocardiac pressure; and dilatation be- 
comes inevitable. Valvular disease develops in association with 
moderate cases of fibrosis when it involves the papillary muscles, 
even in the presence of cardiac hypertrophy. In cases in which the 
sclerotic process is extreme and associated with cardiac dilata- 
tion valvular disease is a constant accompaniment. 

Physical Signs. — The physical findings in chronic myocarditis 
are not characteristic and distinctive, as they vary with the 
stage of the disease and the state of the myocardium. As in the 
acute form of the disease, the heart sounds are usually less mus- 
cular and more valvular in quality; they are accentuated in the 
presence of compensatory hypertrophy; and they are enfeebled 
after dilatation has supervened. The aortic second sound is fre- 
quently accentuated, as the patients often have arterio-sclerosis. 
The pulse is hard and tense, with stiff, unyielding arterial wall, 
and is often disordered in rhythm. The area of cardiac dullness 
is often found extended from cardiac hypertrophy or dilatation. 
Murmurs are encountered in the purely valvular eases and in 
cases associated with cardiac dilatation. 

Diagnosis. — The diagnosis of chronic myocarditis is based 
partially upon the physical signs, but mainly upon the finding of 
arterio-sclerosis in a subject past middle life who presents such 
physical signs. Chronic dyspnea and signs of pulmonary con- 
gestion aid in suggesting the diagnosis. 



CARDIAC HYPERTROPHY 

Pathology. — Cardiac hypertrophy, an overgrowth of the mus- 
culature of the heart, with maintenance of its nutrition, may in- 
volve a single chamber of the heart, one side of the heart, or the 
entire organ. The portion most commonly involved is the left 
ventricle. 

Thickening of the wall of the heart with enlargement of the 
chamber is termed eccentric hypertrophy. A similar mural 
change with decrease in the size of the chamber is termed con- 
centric hypertrophy, a condition which has not been demon- 
strated to the satisfaction of many clinicians. 

The cause of cardiac hypertrophy is increased work thrown 
upon the heart while its nutrition is maintained. The causes of 
this overwork may reside within the heart ; or without the viscus. 



286 



PHYSICAL DIAGNOSIS 



Among the commoner causes of cardiac hypertrophy may be 
mentioned: 

1. Continued excessive muscular exertion, as noted in athletes 
and laborers. 

2. Interference with the cardiac action by pericardial ad- 
hesions. 

3. Over-eating habitually, and excessive drinking of beer. 

4. Diseases of the nervous supply of the heart leading to 
cardiac over-action. 

5. Arterio-sclerosis and nephritis, which by raising the blood 




Fig. 139. — Enormous hypertrophy of left ventricle due to prolonged increased peripheral 
resistance. Note that the whole anterior surface of the heart is occupied by the left 
ventricle. The right ventricle does not appear to be much affected. (From Warfield.) 



pressure in the general circulation cause hypertrophy of the left 
ventricle. 

6. Disease of the lung such as hypertrophic emphysema and 
chronic interstitial pneumonia, and left sided valvular lesions, 
which by raising the blood pressure in the pulmonary circuit 
cause hypertrophy of the right ventricle. Also congenital heart 
disease results in cardiac hypertrophy. 

7. Hypertrophy of the left auricle is caused by mitral regur- 
gitant or stenotic lesions. 

8. Right auricular hypertrophy is caused by tricuspid stenosis 
or regurgitation. 

9. Pregnancy causes some hypertrophy of the heart. 



DISEASES OF THE MYOCARDIUM 287 

The hypertrophied hearl is increased in size, sometimes to 
such an extent that it constitutes the cor bovinum. 

The contour or shape of the hypertrophied heart varies in dif- 
ferent degrees and varieties of hypertrophic change. In total 
hypertrophy of the heart the organ is round. In left ventricular 
hypertrophy and right ventricular hypertrophy respectively 
these portions of the heart are abnormally la rye. 

Physical Signs. — Inspection. — In left ventricular hypertrophy 
the cardiac impulse is forcible and heaving and displaced down- 
ward and to the left. There is precordial bulging especially notable 
in children and women, and often systolic pulsations in the carotid 
arteries. The extent or area of the cardiac impulse is increased. 

Palpation confirms the displacement of the apex beat and its 
firm heaving quality. The valve shock over the aortic valve is 
increased. The pulse is regular, full, and tense. The cardiac 
impulse is not fast; it is slow and heaving; does not occur quickly, 
but slowly and in a heaving manner. The impulse may be found 
in the sixth or even in the seventh interspace. 

The cardiac impulse may not be either visible or palpable if 
hypertrophic emphysema causes the anterior borders of the lung 
to come between the heart and chest wall. 

Percussion. — The transverse dullness of the heart is increased 
to the left and downward. It may extend past the mid-clavicular 
line and well beyond the right of the sternum. 

Auscultation shows accentuation and sometimes reduplication 
of the aortic second sound. The first sound at the apex is also ac- 
centuated. There is in some cases a systolic murmur audible at 
the mitral area. A tinkling sound may be heard sometimes to the 
right of the cardiac apex. A cardio-repiratory murmur may be 
encountered in some instances due to the strong impact of the 
hypertrophied ventricle against a portion of lung anchored an- 
terior to the heart by pleural adhesions. When the valves are 
not diseased the first sound of the heart in addition to being ac- 
centuated is rather prolonged. When the hypertrophy is caused 
by valvular lesions these are audible, or when dilatation is about 
to supervene, relative murmurs may be heard due to stretching 
of the mitral ring. 

Right Ventricular Hypertrophy 

Inspection. — There is undue prominence or bulging of the lower 
sternum and epigastric pulsation, systolic in time. There is also 



288 PHYSICAL DIAGNOSIS 

systolic impulse to the right of the sternum in the sixth and seventh 
interspaces. Pulsation is often noted above these levels; the 
apex beat is displaced to the left ; but there is little if any down- 
ward displacement. 

Palpation reveals the presence of the pulsation at the lower 
end of the sternum and in the epigastrium; but the thrust is not 
as strong and as distinct as it is in the case of left ventricular 
hypertrophy. The valve shock over the pulmonic valve is stronger 
than is that over the aortic area. There is occasionally a pal- 
pable impulse transmitted to the liver by the over-acting heart, 
which should not be confused with the systolic pulsation of that 
organ occurring with tricuspid regurgitation. 

Percussion. — Percussion shows that the area of cardiac dullness 
is increased toward the right, sometimes extending an inch to the 
right of the sternum or more. 

Auscultation. — The tricuspid first sound is accentuated and 
somewhat prolonged, and a systolic "safety-valve leak" is some- 
times demonstrable when ventricular failure is imminent. The pul- 
monic second sound is accentuated. Reduplication of the second 
sound is not infrequent. 

The pulse is of small volume but regular, unless dilatation is 
imminent, in which case it is arrhythmic. 

Left Auricular Hypertrophy 

Left auricular hypertrophy can seldom be ascertained by 
physical means. An extension of cardiac dullness to the left of 
the sternum in the second and third interspaces is sugges- 
tive when found, and, if the hypertrophy is due to mitral 
stenosis, the pre-systolic murmur of this condition may be heard. 
Or, if it is due to mitral regurgitation, this murmur may be 
audible. 

Right Auricular Hypertrophy 

There is apt to be an increase in the area of heart dullness to 
the right side of the sternum in the third and fourth interspaces. 
Pre-systolic pulsation to the right of the sternum in this region 
sometimes is seen. These signs with the signs of right ventricular 
hypertrophy and a systolic murmur at the tricuspid valve are 
very suggestive of right auricular hypertrophy. Systolic pulsa- 
tions in the jugular veins are common and there are usually 
signs of engorgement of the general venous system. 



DISEASES OP THE MYOCARDIUM 289 

Diagnosis. — Cardiac hypertrophy is indicated by a well defined 
set of physical signs. These are: 

1. The heaving character of the cardiac impulse. 

2. The increase in the area of cardiac dullness. 

3. Accentuation of the second sounds of the heart. 

4. The hard tense pulse of full volume. 

Certain other conditions simulate cardiac hypertrophy and re- 
quire differentiation. 

Thus fibroid retraction of the left lung may cause a wide im- 
pulse simulating- cardiac hypertrophy. But the physical signs 
of cirrhosis of the lung or chronic interstitial pneumonia are 
quite sufficient to render a differential diagnosis comparatively 
easy. 

Neurotic conditions such as the over-use of stimulants or to- 
bacco, or exophthalmic goiter, cause vigorous heart action oc- 
casionally simulating true cardiac hypertrophy, but arc dif- 
ferentiated with comparative ease. In these conditions the im- 
pulse is less diffuse and heaving, and there are ameliorations and 
aggravations of the attacks. 

In pericardial effusion the increased cardiac area is triangular 
or pear-shaped Avith the base directed downward toward the dia- 
phragm, and the heart sounds are feeble, and the pulse para- 
doxic. 

In cardiac dilatation the heart sounds are feeble, but distinct, 
and the pulse is feeble and irregular, and cardiac murmurs may 
be detected. There are also signs of general venous stasis. 

CARDIAC DILATATION 

Pathology. — Cardiac dilatation is an enlargement of the cham- 
bers of the heart, due to stretching of the cardiac walls, in 
which the chambers are unable to expel their contents during 
systole. Clinically cardiac dilatation may be said to have its 
inception when the heart is no longer able to empty itself during 
systole. 

The cause of cardiac dilatation resides in increase of intra- 
ventricular tension, or weakening of the cardiac wall. In many 
instances there is a combination of these two factors at work in 
the production of cardiac dilatation. 

Among the factors Avhich tend to produce cardiac dilatation 
may be mentioned: 



290 



PHYSICAL DIAGNOSIS 



1. Prolonged muscular exertion, notably in mountain climbing 
and foot racing. 

2. Sudden exertion in the presence of a valvular lesion or 
chronic myocarditis. 

3. Valvular heart lesions. In stenosis or regurgitation at the 
aortic valve the left ventricle first hypertrophies and then dilates ; 
a mitral regurgitation develops from stretching of the auriculo- 
ventricular ring. The left auricle hypertrophies in the effort to 
compensate for the insuniciency and then dilates. The blood is 




Fig. 140. — Aortic incompetence with hypertrophy and dilatation of left ventricle, 
the result of arteriosclerosis affecting the aortic valves. Note how the valves have 
been curled, thickened, and shortened, the edges of valves being a half inch below 
the upper points of attachment. The anterior coronary artery is shown, the lumen 
narrowed. (Reduced one-half.) (From Warfield.) 



dammed back into the pulmonary circuit and the pressure therein 
raised, leading to catarrhal condition of the bronchial tubes and 
to right ventricular hypertrophy; and later dilatation and in- 
sufficiency; and then the right auricle hypertrophies and dilates, 
with a leak at the tricuspid valve, the ultimate result being 
venous congestion of the general circulation, with pulsation of 
the liver and edema of the lower extremities or anasarca. 

/ 



DISEASES OF THE MYOCARDIUM 291 

4. The toxins of infectious diseases, notably influenza, typhoid 
fever, pneumonia, and erysipelas, affecting the myocardium pro- 
duce dilatation or yielding of the weakened cardiac walls. 

5. Conditions of malnutrition and anemia weaken the myo- 
cardium and lead to dilatation. 

6. Causes raising arterial pressure in the general circulation, 
as arterio-sclerosis and nephritis. 

7. Conditions raising arterial pressure in the pulmonary circu- 
lation as hypertrophic emphysema, chronic interstitial pneumonia 
or other obstructive lung disease. 

Thus it is apparent that cardiac dilatation is most commonly 
the result of valvular lesions, regurgitant or stenotic, and is usually 
preceded by cardiac hypertrophy. 

Cardiac dilatation is associated with relative insufficiency 
caused by stretching of the auriculo-ventricular rings, so that al- 
though the valve leaflets are themselves not diseased, they are 
unable to co-aptate and close the abnormally large orifice. 
Moreover, the chordae tendinese and papillary muscles do not 
share in the dilatation, do not stretch, but being of normal length, 
do not permit the co-aptation of the valve edges. 

As in cardiac hypertrophy, the contour of the heart varies with 
the type or degree of dilatation present. When dilatation in- 
volves all four chambers of the heart, the heart is rather round 
or spherical. When a single chamber, or one side of the heart is 
dilated, the contour is irregular. The right ventricle is anatom- 
ically liable to a greater degree of dilatation than is the left 
ventricle; and the left auricle to more than is the right auricle. 

The myocardium is thinner than normal and shows different 
stages of fatty or albuminoid degeneration. 

Physical Signs. — Inspection. — The cardiac impulse is diffuse 
and often undulatory in type. It is often displaced to right or 
left. In extreme dilatation, when the auricles are involved, pul- 
sation to the right of the sternum in the third interspace is occasion- 
ally visible. 

Palpation. — The cardiac impulse is hard to define and is weak in 
strength, or is altogether impalpable. A visible diffuse cardiac 
impulse which is not palpable is of great diagnostic significance. 
Epigastric tenderness can usually be elicited in right ventricular 
dilatation. The pulse is weak and irregular. 

Late in the course of right sided cardiac dilatation the systolic 
pulsation of the liver becomes palpable. 

Percussion. — The area of cardiac dullness is increased to the 



292 PHYSICAL DIAGNOSIS 

right and left, and, in auricular dilatation, along the left border of 
the sternum as high as the second interspace. If emphysematous 
lung- intervenes between the heart and the thoracic wall, it may 
obscure to a great extent the cardiac enlargement. 

Auscultation. — The cardiac sounds upon auscultation of the pre- 
cordia are enfeebled. The first sound is not infrequently redu- 
plicated, as also may be the second sound. The pulmonic sound 
is strong if the left side of the heart is dilated while the right 
is hypertrophied. This sound is weak or feeble if the right heart 
participates in the dilatation. Gallop-rhythm or canter-rhythm 
is not infrequent in the late stages of the disease. Murmurs due 
to mitral or tricuspid regurgitation, as well as aortic and pul- 
monary murmurs are usually audible. 

Diagnosis. — The character of the heart sounds, the increased 
extent of the cardiac dullness, the diffuse, wavy and displaced 
cardiac impulse, and signs of systemic venous engorgement, ren- 
der the diagnosis not difficult. 

The enlarged heart of cardiac hypertrophy is differentiated by 
the strong cardiac impulse, distinctly visible and displaced, the 
accentuated second sounds, the full and regular pulse, and the ab- 
sence of signs of cardiac failure as venous congestion. 

From pericarditis with effusion the differential points are men- 
tioned under that disease (page 258). 

Increased dullness to the left of the heart due to consolidation 
of the lung is usually differentiated by the presence of bronchial 
breath sounds and rales. 

The cardiac area may be broadened by pushing of the heart for- 
ward by the pressure of a mediastinal tumor, but these tumors 
produce pressure symptoms which are not present in cardiac dila- 
tation. 

Encysted pleurisy may be confused with cardiac dilatation by 
broadening the area of dullness around and adjacent to the 
heart; but there is usually the friction rub, and the heart sounds 
are not changed and there are no signs of cardiac or circulatory 
failure. 

The presence of hypertrophic emphysema by interposition of 
the anterior borders of the lungs between the heart and chest 
wall may mask the cardiac enlargement to a variable degree, 
and require careful percussion to bring out the increased size of 
the organ. 



DISEASES OF THE MYOCARDIUM 



293 



CONGENITAL HEART DISEASE 

Pathology. — Pulmonary stenosis is the most frequent and 
clinically the most important of the congenital lesions of the 
heart. The stenosis may be complete, the orifice of the vessel 
being closed by a fibrous membrane, or may permit all grades of 
patency. In addition to obstruction at the valve there may be 
narrowing of the conus arteriosus of the right ventricle, or the 




Fig. 141. — Reptilian heart. (.From Delaftekl and Prudden.) 



pulmonary artery may be congenitally narrow beyond the val- 
vular opening. 

Probably the second most common congenital lesion of the 
heart is the patent foramen ovale, which normally closes during 
the first week of extrauterine life, but which may remain par- 
tially open to adult life in from 2 to 5 per cent of persons. 

The interauricular septum may be found absent, resulting in 
the reptilian heart or cor triloculare. In other instances both 
the interauricular and interventricular septa are absent, the 
heart consisting of only two chambers, the cor biloculare. 



294 PHYSICAL DIAGNOSIS 

In a certain number of cases the ductus arteriosus, which usu- 
ally closes during the first month of extrauterine life remains 
patent to give rise to signs of congenital heart disease. 

Congenital lesions of the aortic, mitral and tricuspid valves are 
rarely encountered. Of the various valves of the heart, there 
may be supernumerary cusps or a diminution of the number of 
cusps, or adhesions between them, or merely a button-hole slit in 
a membrane closing a valve. 

In certain rare instances the aorta is found to arise from the 
right ventricle and the pulmonary artery from the left ven- 
tricle ; while in conditions of visceral transposition the heart lies 
chiefly in the right side of the thorax. 

Physical Signs. — The physical signs of congenital heart dis- 
ease are early apparent, the most striking sign being extreme 
blueness or cyanosis of the child. However, cyanosis may be 
absent in the presence of congenital cardiac disease. The finger- 
tips are often clubbed, the so-called Hippocratic fingers. Dysp- 
nea is always present. . 

As pulmonary stenosis is the most frequent underlying lesion 
there is in most cases a systolic blowing murmur to the left of the 
sternum in the pulmonic area, with signs of hypertrophy of the 
right ventricle. On the other hand, ' a patent ductus arteriosis 
yields a rather prolonged systolic murmur in the same area which 
is, however, more distinctly audible in the third left interspace. 

Diagnosis. — A diagnosis of congenital heart disease can be read- 
ily made in most instances on the extreme cyanosis, dyspnea, 
clubbed fingers, and loud blowing murmurs. However, it is 
often very difficult to say with certainty just what the underly- 
ing lesion is, as the signs are often confusing and often two con- 
ditions coexist in the same case. The murmurs of congenital 
disease are very difficult to differentiate from functional mur- 
murs in anemic children; but it should be borne in mind in this 
connection that functional murmurs are not transmitted and do 
not produce alterations in the myocardium, as hypertrophy. 
From acquired heart disease, congenital disease is usually dif- 
ferentiated by the fact that it is present from birth, the baby 
often having been from birth very blue (morbus coeruleus) ; 
that the child is under two years of age, at which time acquired 
lesions are practically unknown; and that the murmurs are atyp- 
ical in location and transmission. 



PART II. THE ABDOMEN 



SECTION I 
GENERAL EXAMINATION OF THE ABDOMEN 



CHAPTER XX 

CLINICAL ANATOMY OF THE ABDOMEN 

The abdomen, the portion of the trunk which is limited above 
by the ensiform cartilage and costal arch, and below by the pubic 
crest and Poupart's ligaments, has a roughly oval form, the 
shape varying, however, with the age and sex of the subject. 

Thus, the abdomen of a child is roughly conical with the apex 
inf eriorly ; while in the adult female, owing to the broad pelvis 
in this sex, it is roughly conical with the apex above; whereas in 
the adult male the abdomen is oval or barrel-shaped, with a mod- 
erate antero-posterior flattening. 

The abdominal cavity is limited above by the lower surface of 
the diaphragm, and interiorly by the levator ani, assisted by the 
coccygeus, these two muscles constituting the pelvic diaphragm. 
The more roomy upper portion of the abdominal cavity, above the 
brim of the pelvis is termed the abdomen proper, while the smaller 
portion below the pelvic inlet is termed the pelvis. 

The abdominal cavity is not limited above by the costal arch, 
which forms its upper boundary upon the surface of the abdomen, 
but by the diaphragm, extending upward into the bony thorax for 
some distance. On the right side its upper limit is on a level 
with the upper border of the fifth rib in the mid-clavicular line; 
while on the left side its upper limit is approximately one-half 
inch lower in the same line. 

The abdominal wall is composed largely of muscle and soft struc- 
tures, reinforced in certain regions by bony structures. Anteriorly 
and laterally the wall is formed of the abdominal muscles, the 
lower ribs, and the iliac bones. Posteriorly it is formed by the 

295 



296 



PHYSICAL DIAGNOSIS 



posterior abdominal muscles, the quadratus lumborum and psoas 
on either side, and in the median line by the vertebral column. 
The anterior abdominal wall and the lateral walls between the last 
rib and the iliac crest are devoid of bony support and are subject 
to distention and retraction, depending upon the state of the 
abdominal contents. 



Lower lung J ^1\ 

limit 



l.mrcr pleural J 



Diaphragm 



I'f rilrmaim—i—f~- 





q|* ■'-..' Heart ronton/- 




. — -small- interim 
■ \ 



'i/tllt'l'l 

tie. rare 






w 

%■ 



Fig. 142. — Relations of abdominal and thoracic viscera. (From Gray.) 

Anatomical Landmarks of the Abdomen. — At the upper limit 
of the anterior abdominal surface in the median line is the ensi- 
form cartilage, with the costal arch descending from it upon either 
side. The anterior extremities of the seventh, eighth, ninth and 



CLINICAL ANATOMY OF ABDOMEN 



297 



tenth costal cartilages are palpable, and. in thin patients, the \'rc<> 
extremities of the eleventh and twelfth ribs as well. 

At the lower limit of the abdomen the symphysis pubis with its 
pubic spines are found, and extending from them in an upward 
and outward direction Poupart's ligaments on either side. 



Male Type 



Infantile Type 



B 



Femab Type 



Fig. 143. — Schematic outlines of abdominal contour. (From I 



Lineae transversa — 

Linae semilunaris — 

Situation of 
fat grooves 
in the obese — 




Beginning qi 
abdominal aorta 

Celiac axis 
Renal artery 

Superior mesenteric 
artery 

Inferior mesenteric 
artery 

Bifurcation of 
aorta 



Fig. 144. — Showing the surface and bony landmarks of the abdomen and the location 
of the abdominal aorta and its more important branches. (From Butler.) 



At the lower and lateral regions the iliac crest, terminating an- 
teriorly in the anterior superior iliac spines are encountered, the 
latter being plainly palpable in very obese subjects. 

In the lower central region of the abdominal surface the umbili- 



298 



PHYSICAL DIAGNOSIS 



cus is noted. It corresponds to the disc between the third and 
fourth lumbar vertebras. 

The linea alba extends in the mid-line from the ensiform cartilage 
to the symphysis pubis. It is indicated by a slight groove in the 
median line of the abdomen above the umbilicus, and by a line of 
hair or of brown pigment (Linea Nigra) below the umbilicus. 




Fig. 145. — The abdominal surface with the rib margins and the iliac crests out- 
lined. (From Crossen.) 



The linea semilunaris, on either side of the abdomen ex- 
tends with a sHght convexity outward from the junction of the tip 
of the ninth costal cartilage with the outer border of the rectus 



CLINICAL ANATOMY OF ABDOMEN 



299 



muscle to the pubic spine. It corresponds accurately to the outer 
limit of the sheath of the rectus muscle. 

Linece transversa, are to be noted in subjects of good muscular 
development. They are transverse constrictions in the recti mus- 




Fig. 146. — Another abdominal surface, with the ribs and crests outlined. This 
patient is rather stout. Notice how much the landmarks differ from those in Fig. 145. 
(From Crossen.) 



cles. They are three in number, as a rule, although a fourth may 
sometimes be found. One is located at the ensiform cartilage, an- 
other at the umbilicus, and a third midway between the two. When 



300 



PHYSICAL DIAGNOSIS 



a fourth is present, it is located midway between the umbilicus and 
symphysis pubis. 

Cutaneous flexion folds are encountered in obese subjects. They 
are usually two in number, one at the level of the umbilicus and the 
other just above the symphysis pubis. 

Surface Markings. — The course of the abdominal aorta cor- 
responds to a vertical line upon the surface of the abdomen extend- 
ing from a point a little to the left of the ensiform process down- 




Fig. 147. — Anterior view of abdominal viscera in situ. (From Gray.) 



ward to a point three-fourths of an inch below and a little to the left 
of the umbilicus, where the vessel bifurcates to form the common 
iliac arteries. (See Fig. 229, p. 368.) 

The course of the common iliac and external iliac arteries corre- 
sponds to a line drawn from the point of bifurcation of the aorta to 
a point midway between the anterior superior iliac spine and the 
symphysis pubis. 



CLINICAL ANATOMY OF ABDOMEN 301 

The course of the deep epigastric artery is represented by a line 
drawn from the mid-point of Poupart's Ligament upward and in- 
ward to the umbilicus. 

The course of inferior vena cava is represented by a vertical line 




Fig. 148. — Surface markings of chief thoracic and abdominal viscera. Posterior view. 
(From Eisendrath.) 

/, pharynx; 2, esophagus; 3, left recurrent laryngeal nerve; 4, right recurrent laryn- 
geal nerve; 5, bifurcation of trachea; 6, arch of aorta; 7, liver; 8, cardiac portion of stom- 
ach; 0, and 10, duodenum; 77, head of pancreas; 12, spleen; 73, descending colon; 14, 
ascending colon; 75, left kidney; 16, right kidney; LV , left vagus nerve; RV, right vagus 
nerve. 



302 



PHYSICAL DIAGNOSIS 



drawn along the line representing the course of the abdominal aorta, 
a little to its right side. 

The common and external iliac veins are indicated by lines upon 
the abdominal surface slightly below and to the right of and cor- 
responding in direction to the lines of the arteries of the same name. 




Fig. 149. — Relations of thoracic and abdominal viscera in the child. (From Kisendrath.) 
i, thymus gland; 2, outline of right pleura; 2', left pleura; 3, lower border of right 
lung; 3', lower border of left lung; 4, upper border of liver (note large size of this 
organ in child); 4', lower border of liver; 5, interlobar fissure between right upper and 
right middle lobes; 6, interlobar fissure between right middle and right lower lobes; 
6', fissure between left upper and left lower lobes; 7, gall-bladder; 8, transverse colon; 
9, ascending colon and cecum; jo, descending colon; 11, appendix; 12, internal abdominal 
ring; 13, external abdominal ring; P, pericardium. 



CLINICAL ANATOMY OF ABDOMEN 303 

The surface markings of the various abdominal organs are 
given in the sections dealing with the organs. 

Topographical Anatomy of the Abdomen. — For purposes of de- 
scription and to facilitate the localization of morbid conditions 




Fig. 150. — Surface markings of chief thoracic and abdominal viscera. Anterior view. 
(From Eisendrath.) P, pleura; L, lung; MC, midclavicular line; D, upper level of dia- 
phragm; RL, right lobe of liver; LL, left lobe of liver; LC, lesser curvature of stomach; 
GC, greater curvature of stomach; Y, pylorus; G, gall-bladder; SF, hepatic flexure of colon; 
HF, splenic flexure of colon; D, ascending portion of duodenum; Y to D, horizontal 
and vertical portions of duodenum; C, cecum; A, appendix; B, pelvic brim; X, McBurney's 
point; T, transverse colon; DC, descending colon; PC, pelvic colon, or sigmoid flexure; 
R, rectum; IS, fissure between upper and middle lobes of right lung; IF, fissure between 
middle and lower lobes of right lung; H, portion of pericardium which is not covered by 
pleura. 



304 



PHYSICAL DIAGNOSIS 



arising within the abdominal cavity, the abdomen is divided into 
nine regions by four lines drawn upon the surface of the abdo- 
men. Two of these lines are drawn around the body in a hori- 
zontal direction, while two are erected perpendicualrly upon its 
anterior surface. The upper horizontal line, the sub-costal line is 
drawn around the body at the level of the most dependent portion 
of the tenth costal cartilage. The lower horizontal line, the inter- 




Fig. 151. — The usual anatomic division of the abdomen into nine regions by two 
transverse lines and two vertical lines. The upper transverse line is at the level of 
the cartilages of the tenth ribs, and the lower with the highest points of the iliac crests. 
The two parallel vertical lines pass through the cartilages of the eighth ribs and the 
middle of Poupart's ligaments. (From Crossen.) 



tubercular line, encircles the trunk at the level of the tubercle 
which is found upon the iliac crest two inches behind the anterior 
superior iliac spine. The two perpendicular lines are projected 
upward from the mid-point of Poupart's ligament upon either side, 
blending with the mid-clavicular lines of the thorax. 

By means of these lines the abdominal cavity is divided into nine 



CLINICAL ANATOMY OF ABDOMEN 305 

arbitrary regions. The epigastric region, bounded inferiorly by the 
sub-costal line, and superiorly and laterally by the costal arch, over- 
lies the stomach, duodenum, liver, gall-bladder, pancreas and kid- 
neys. 

The left hypochondriac region, limited inferiorly by the sub- 
costal line and internally by the line of the costal arch, overlies 




Fig. 152.- — The abdominal surface divided into quadrants. (From Crossen.) 

the fundus of the stomach, the spleen, and the splenic flexure of 
the colon. 

The right hypochondriac region, limited inferiorly by the sub- 
costal line and internally by the line of the right costal arch, over- 
lies the portion of the abdominal cavity which is occupied by the 
liver and right kidney. 

The umbilical region, limited above by the sub-costal line, infe- 
riorly by the inter-tubercular line, and laterally by the right and 



306 



PHYSICAL DIAGNOSIS 



left mid-Poupart lines, overlies the small intestines, the mesentery, 
the great omentum, the kidneys, and the transverse colon. 

The left lumbar region, bounded above by the sub-costal line, be- 
low by the inter-tubercular line, and internally by the left mid- 
Poupart line, overlies the left kidney, the descending colon, and 
small intestine. 



llfht 



/ kf.htr 



Uhh$ 




x & 'Lower 



limit & 




Fig. 153. — Another abdomen divided with the circle snd short horizontal lines, and 
showing the names on the primary regions. The area within the circle carries the 
usual designation, "umbilical region." (From Crossen.) 



The right lumbar region, limited by the sub-costal, inter-tubercu- 
lar, and right mid-Poupart lines, overlies the right kidney, the as- 
cending colon, and small intestine. 

The hypogastric region, lying below the inter-tubercular line and 
limited laterally by the micl-Poupart lines and inferiorly by the 
pubic bone, overlies the distended bladder, the small intestine, the 



CLINICAL ANATOMY OF ABDOMEN 307 

sigmoid flexure, the cecum and occasionally the vermiform appen- 
dix, and the pregnant uterus. 

The left iliac region, limited above by the inter-tubercular line, 
interiorly by Poupart's Ligament, and internally by the left mid- 
Poupart line, overlies the sigmoid flexure. 

The right iliac region, limited by the inter-tubercular line, the 
right mid-Poupart line and Poupart's ligament, overlies the cecum 
and vermiform appendix. 

Instead of mapping out nine regions of the abdomen by means 
of two horizontal and two vertical lines, the abdominal cavity 
may be divided into four regions, or quadrants, by a horizontal 
and a vertical line passing through the umbilicus. In this mode 
of subdivision the four regions are termed respectively, the right 
upper quadrant, the left upper quadrant, the right lower quad- 
rant, and the left lower quadrant of the abdomen. While this is 
a very practical and convenient division of the abdominal cavity 
and suffices for clinical description in many instances, the divi- 
sions are not sufficiently circumscribed for use in the description 
and localization of small tumors or masses arising within the 
abdominal cavity. 

An eminently satisfactory subdivision of the abdominal cavity 
is that devised by Crossen, in which the natural landmarks of 
the abdomen are utilized, the only artificial lines employed being 
one encircling the umbilicus, and a horizontal line drawn from 
either side of the circle. By this method the abdomen is subdi- 
vided into regions which are respectively designated as right 
upper, left upper, central upper, right lower, left lower, central 
lower, umbilical, right lumbar, and left lumbar. This method 
of subdivision is very serviceable in the preparation of clinical 
charts. 



CHAPTER XXI 
INSPECTION OF THE ABDOMEN 

Technic. — During inspection of the abdomen the patient should 
first be directed to assume the dorsal decubitus, the position in 
bed or on the examining table being absolutely symmetric and un- 
constrained. The subject should be covered by a sheet which 
may be turned down, exposing the abdomen to within a short dis- 
tance of the pubic bone. The abdomen should be inspected in 
direct light, and then in oblique light, the latter often revealing 
slight pulsations or enlargements or vermicular movements which 
escaped detection during the examination in direct light. 

For the purpose of detecting certain phenomena such as vis- 
ible peristalsis and visceral ptosis an additional inspection should 
be made with the patient in the standing posture. 

Finally, the patient should be examined in the knee-chest pos- 
ture which allows movable tumors Avithin the abdominal cavity to 
fall forward and become more clearly visible. 

The Skin of the Abdomen. — The abdominal skin is lax and loose 
in the emaciation of chronic wasting disease, and is tense and 
glistening in the presence of abdominal distention from acites. 
abdominal tumor, or pregnancy. Whitish or silvery streaks, 
lineae albicantes, over the lower portion of the abdomen and the 
upper portions of the thighs are indicative of past abdominal dis- 
tention, either from tumor, ascites, or pregnancy. 

Scars upon the abdomen may result from surgical operations, 
the eruption of syphilis or other skin disease. A scar in the 
groin is suggestive of suppuration of an inguinal gland which has 
opened spontaneously or has been opened by the surgeon. 

The Linea Nigra, a line of brown pigment in the median line 
below the umbilicus accompanies pregnancy and chronic abdom- 
inal distention from other cause. 

The abdomen is the usual site of the cutaneous eruption of ty- 
phoid fever, the rose spot. These spots are small, hyperemic, 
slightly elevated spots, which disappear upon pressure. In cer- 
tain instances the papule is surmounted by a small vesicle. They 
are not confined to the abdomen, although most commonly en- 

308 



INSPECTION OF ABDOMKX 309 

countered there, but may appear upon the back, arms, or thighs. 
The rose spots appear in successive crops, disappearing in two or 
three days, sometimes leaving a brown stain. 




Fig. 154. — Establishment of collateral circulation in portal vein obstruction and mediastinal 

tumor. 
i, internal mammary veins: 2, anterior intercostal veins: J, posterior intercostal veins: 
4, radicles of 2; 5, subclavian vein; 6, deep epigastric vein; J, external iliac vein; 8, super- 
ficial circumflex iliac vein; 9, internal saphenous vein; 10, caput medusae. 

During pregnancy the abdominal skin sometimes shows brown- 
ish areas of discoloration, chloasma. 



310 PHYSICAL DIAGNOSIS 

Enlargement of the Superficial Veins of the Abdomen. — In por- 
tal obstruction from cirrhosis of the liver there is present upon the 
abdominal Avail a series of distended superficial veins extending 




Fig. 155. — Abdominal arteries in a case of double iliac thrombosis of typhoid origin. 
(Woolley, after Thayer.) 

outward from the umbilicus in a radial manner, constituting the 
caput medusas. A distention of the superficial veins over the ab- 
domen, communicating with similarly distended veins over the 



INSPECTION OF ABDOMEN 



311 




Fig. 157. — A large ventral hernia at the site of an operation scar. (Crossen after Hirst/) 




Fig. 158. — Ventral hernia. 



312 



PHYSICAL DIAGNOSIS 



thorax is indicative of portal vein obstruction by hepatic cir- 
rhosis or tumor, chronic ascites, or pressure upon the inferior or 
superior vena cava by abdominal or mediastinal tumor. The di- 
rection of the blood flow in the distended vein is an index to the 



XT 



l^ta^tf 



V 





Fig. 159. — Stenosis in the vicinity of the splenic flexure. (Austin, after Nothnagel.) 



site of the obstruction. If upon compressing the vein it is found 
that the direction of the blood current is upward the obstruction 
is in the portal vein or inferior vena cava; whereas, if the cur- 
rent is downward the obstruction is in the superior vena cava. 



INSPECTION OF ABDOMEN 



313 



This venous distention is an evidence of the effort at the establish- 
ment of collateral circulation in the presence of obstruction of 
the usual channels. 




Fig. 160. — Stenosis of 



the lower ileum from peritoneal adhesion. 
Nothnagel.) 



(.Austin, after 



The Umbilicus. — The umbilicus should be examined for pro- 
trusion, retraction, skin eruptions, and inflammation. A pro- 
truding umbilicus is noted in umbilical hernia, the latter months 
of pregnancy, portal vein obstruction, ascites or abdominal dis- 



314 PHYSICAL DIAGNOSIS 

tention due to large tumor of ail intra-abdominal organ. The 
umbilicus is retracted in the obese subject. 

Enlarged Glands. — The glands in the groin are enlarged as a 
result of venereal infection or localized non-specific inflammation 
resulting from abrasions about the external genitalia of the lower 
extremities. The character of the enlargement, whether hard or 
soft and fluctuating, and whether the glands remain separated and 
discrete or are matted together should be determined. 




v$ 



Fig. 161. — Normal intestinal peristalsis. (Austin, after Nothnagel.) 

Visible Peristalsis. — The peristaltic movements of the stomach, 
small intestine, or large intestine, at times become visible as a 
vermicular movement upon the abdominal Avail. In its exagger- 
ated form it is indicative of obstruction located at the pylorus, in 
the small intestine, or in the colon. The peristaltic movement of 
the stomach is visible under these circumstances in the upper por- 
tion of the abdomen, pursuing a direction from left to right and 
slightly downward. Visible peristalsis of the small intestine is 



INSPECTION OF ABDOMEN 



315 



chiefly confined to the umbilical region, whereas that occasioned 
by obstruction in the large intestine is observed over the course 
of the colon. When not very pronounced this peristaltic move- 
ment of the abdominal wall may often be accentuated by apply- 
ing a cold hand to the surface of the abdomen or by nicking 
the abdominal surface with a towel wet in cold water. When the 
site of the obstruction is in the ilium just proximal to the ileo- 
cecal valve, the visible peristalsis assumes a "ladder pattern" the 
waves lying one above the other in the umbilical region. 
Visible peristalsis observed in extremely emaciated patients 



\ 




Fig. 162. — Median grooving of the abdominal wall where there is separation of the recti 
muscles. The woman is represented as lying on her back. (Crossen, after Webster.) 



with very thin abdominal walls, or in women in whom repeated 
pregnancies have caused a diastasis of the rectus muscles possesses 
little, if any, significance. 

Abolition of the Respiratory Movements of the Abdomen. — Fix- 
ation of the abdominal Avail with inhibition or abolition of the 
respiratory movements is indicative of pain arising within the 
abdominal cavity, usually due to peritonitis. 



316 



PHYSICAL DIAGNOSIS 





X 



^£_ 



Fig. 163. — Obesity. The most prominent feature in this case is the marked obesity — 
see Fig. 164. There is also a fibroid tumor of the uterus and a small amount of 
ascitic fluid. (From Crossen.) 




Fig. 164. — Obesity. Patient standing. Same patient as shown in Fig. 163. Notice 
the thick roll of subcutaneous fat that drops down below the general contour of the 
abdomen. 



INSPECTION OF ABDOMKX 



317 



VARIATIONS IN THE CONTOUR OF THE ABDOMEN 

The normal abdomen is symmetrical with a moderate degree of 
antero-posterior flattening in the male, is of uniform Tension, and 
a moderate bulging of the lower portion in female subjects. The 
umbilicus is nether unduly depressed nor protrudng. 




Fijj. 165. — Obesity, mistaken for pregnancy by patient. ( Crosscn, after Williams.) 




Fig. 166. — Contour of the abdomen in pregnancy with patient recumbent. (Crossen, 

after Edgar.) 



318 PHYSICAL DIAGNOSIS 

Symmetric Enlargement 

Obesity. — In the obese subject the abdomen is symmetrically 
enlarged, the cutaneous flexion folds are accentuated, the um- 
bilicus is depressed, and the lower portion of the abdomen is pen- 
dulous, encroaching to a variable extent upon the thighs and 
pubes. 

Pregnancy. — The abdominal enlargement accompanying preg- 
nancy is progressive, increasing gradually as the uterus rises out 
of the pelvis and occupies the abdominal cavity. In its fully de- 
veloped state the umbilicus protrudes, the abdominal skin presents 
the lineae albicantes, and the abdominal distention is accompanied 




Fig. 167. — Tympanites, mistaken for pregnancy by the patient. The small figure in 
the upper corner shows the internal condition as determined by bimanual examination, 
the uterus being of normal size. (Crossen, after Edgar.) 

by changes in the breasts and the positive signs of pregnancy. 
The abdominal distention is much greater in multiparous women 
than it is in primiparae. 

Meteorism. — Meteorism or tympanites produces symmetrical 
abdominal enlargement, the walls being tense, smooth and shiny, 
affording upon percussion a distinctly tympanitic note, which 
extends high up and decreases the area of normal dullness of the 
liver. The umbilicus protrudes. 

Ascites. — The degree of abdominal enlargement accompanying 
ascites varies with the amount of fluid in the peritoneal cavity. 
With the development of the ascitic fluid there is a gradual and 
uniform enlargement of the abdomen. The contour of the abdo- 



INSPECTION OF ABDOMEN 



319 




Fig. 168. — Extreme ascites. In the patient from which this photograph was taken, 
the abdomen was so distended with fluid that the wall was raised higher than the 
mesentery would permit the intestine to float, giving dullness about the umbilicus as well 
as elsewhere. The rise of the wall from below is rather abrupt There is also edema of 
the wall, as shown by the persisting groove where the skirts were tied about the waist. 




Fig. 169. — Showing the area of dullness in moderate ascites, with the patient lying on 
her back. (From Crossen.) 



320 



PHYSICAL DIAGNOSIS 



men is characteristically altered, the antero-posterior diameter 
increasing with moderate flattening of the lateral regions. In the 




Fig. 170. — Showing the reason for the disposition of the dull and resonant areas in 
case of moderate ascites. (Crossen, after Butler.) 




Fig. 171. — Indicating the relation of the dull and resonant areas in the case of a tumor 
occupying the central lower abdomen. (Crossen, after Butler.) 




v* 






v ■*;*>* 




Fig. 172. — Ascites. Representing the patient turned on one side. The fluid gravitates 
to the under side, leaving the upper flank resonant. (Crossen, after Butler.) 



presence of a large effusion the skin is smooth and tense, not un- 
commonly presenting lineae albicantes. Enlarged tortuous super- 
ficial veins are often present. 



INSPECTION OF ABDOMEN 



321 




Fig. 173. — Indicating the area of dullness in moderate ascites, with the patient standing 

(From Crossen.) 









J 



Fig. 174. — Indicating the area of dullness in a case of moderate ascites, with the patient 
turned on the left side. (From Crossen.) 



322 



PHYSICAL DIAGNOSIS 




Fig. 175. — Abdominal enlargement due to ovarian cyst. 



. 


/ i' V 


1 /%^-r<^ 1'^ ^ 


>>M 1 


<?k 


i lyy^y^M 


iilL^i 


yyy\\ 




y/}\ 




\ KL^ j /N 


^-f ; / / 


1 i - / / 


"i / 


/ I— cA^fvV 


/ 


// 51 s eg 


\ 


//[ , -• , \] /\ 


\ j \ 


( 4( X ■ >-V- ..^^ • ! j* 




i V ^Yjcr '■"-■,-,- \L.>fK 




j It ■ J ^—Xy^ \cf1i 


-''•' / / 


f V, , *f 


y \ 


/ / " > 


\ 


/ --^--^n - v — \ • Vv. '-^--^ ■ •/ 


■ % \ 


/Y V^si 


\ 


r 




/ j x \ -' * < / / 


^ N / L. X 


/ \ 



Fig. 176. — Front view of general enteroptosis. (Kisendrath, after Coffey.) 
L, liver outline on surface; S, stomach (lesser curvature on line with umbilicus, 
greater curvature midway between umbilicus and symphysis) ; KK, right and left kid- 
neys, showing marked downward displacement; T, transverse colon also markedly 
prolapsed. 



INSPECTION OF ABDOMEN 323 

When a patient with ascites assumes the dorsal decubitus the 
percussion note is tympanitic in the median line and flat in the 
flanks, owing to the fact that the intestines float upward in the 
fluid, which gravitates to the dependent portions of the ab- 
dominal cavity. When the patient is placed in the lateral decubi- 
tus there is dullness upon the under side and tympany upon the 
uppermost side for the same shifting of the intestines. Finally, 
upon placing the patient in the knee-chest position there is flat- 
ness in the umbilical and hypogastric regions, and tympany in 
the flanks. 

Visceroptosis. — Ptosis of the abdominal organs produces rather 
characteristic alterations in the abdominal contour with the pa- 
tient in the erect attitude. Thus, in gastroptosis, there is an ab- 
normal flattening of the upper region of the abdomen with undue 
prominence of the central region; whereas, in enteroptosis the 
upper and central regions of the abdomen are flattened while the 
lower region symmetrically bulges; the contour of the abdomen 
resembling that of a gourd. (See Fig. 176, p. 322.) 

Abdominal Retraction. — In chronic wasting disease, prolonged 
diarrhea, and cardiac or pyloric stenosis the abdominal wall is 
generally retracted, the bony landmarks standing out very promi- 
nently. The abdomen appears to be ''scooped out" like a boat, 
the scaphoid abdomen. 

Asymmetrical Variations 

Local bulging of the upper region of the abdomen in the median 
line and laterally may be due to distention of the stomach, or en- 
largements of the liver or spleen, the causes of which are dis- 
cussed in the section upon the examination of these organs. 

Undue prominence or bulging of the umbilical region is signifi- 
cant of umbilical hernia or tumor of an abdominal organ. 

Localized bulging in the hypogastric and iliac regions may be 
due to a distended bladder, a pregnant uterus, uterine myoma, or 
ovarian cyst. 



CHAPTER XXII 

PALPATION, PERCUSSION, AUSCULTATION, AND MEN- 
SURATION OF ABDOMEN 

PALPATION 

Technic. — During palpation of the abdomen the patient should 
assume the dorsal decubitus with the head slightly elevated by a 
small pillow and the knees drawn up and supported by a pillow, 
which relieves the tension of the abdominal wall. In bed-ridden 
subjects a similar state of abdominal relaxation may be attained 
by propping the patient 's shoulders up with pillows and drawing 
up the knees and supporting them. Under certain circumstances 
it is desirable to palpate the abdomen with the patient in the 
knee-chest position. 

The patient having been placed in a natural and unconstrained 
attitude, he should be directed to refrain from the natural ten- 
dency to hold the breath during the examination. 

The hands of the examiner should be warm, as a cold hand 
applied to the surface of the bare abdomen will cause a local 
muscular rigidity which combats and frustrates the object of the 
examination. The examining hand should be first applied very 
gently to the abdominal surface with the palm down and fingers 
extended, avoiding any sudden pressure or punching movements. 
During the course of the examination the examiner should first 
palpate a region which is supposed to be normal before proceed- 
ing to the suspected site of disease, as by so doing he gains the con- 
fidence and co-operation of the patient. 

The abdomen should be palpated systematically, the examiner 
examining the state of the abdominal wall, palpating any local 
bulging or retraction which was noted during inspection, and en- 
deavoring to determine whether it is located in the abdominal 
wall or arises within the abdominal cavity, and the state of the 
various solid organs of the abdomen, the technic of palpation of 
which are discussed in their appropriate sections. 

The Abdominal Wall. — An estimate of the thickness of the ab- 
dominal wall may be made by pinching up the wall between 

324 



PALPATION OF ABDOMEN 



325 




Fig. 177. — Palpation of the abdomen. 
First step. Hand flat on abdominal surface. 
(From Crossen.) 



Pig. 178. — Palpation. Depressing the 
wall with the fingers of one hand, in various 
>en.) 




Fig. 179. — Palpation with both hands. 
(From Crossen.) 



Fig. 180. — Deep palpation with both hands. 
(From Crossen.) 



326 



PHYSICAL DIAGNOSIS 



the forefinger and thumb, or by approximating the two hands 
placed palm downward upon the abdominal surface. Increased 
thickness of the abdominal wall indicates, an excess of fat, 
the presence of edema, or suppuration of the wall. If the in- 
crease be due to excessive deposition of fat in the wall, a fat wave 
will be obtained upon bimanual palpation; if due to edema, the 
wall will pit upon pressure ; and if due to a localized or extensive 
suppuration of the wall, there will be accompanying signs of in- 
flammation, as discoloration of the surface, and elevated tem- 
perature. 

Rigidity of the abdominal wall with possibly spasm upon at- 
tempts at palpation, indicates inflammation of the peritoneum or 
of an abdominal organ. Muscular rigidity is most commonly en- 







£» 1 










i 


/ 






^>* 


^Si 


^SfetA****** 


§0**^ , -^ 




Fig. 181. — Testing the thickness of the 
abdominal wall. (From Crossen.) 



Fig. 182. — Testing the thickness of the 
abdominal wall. — Second step. The ringers 
carried beneath the wall. (From Crossen.) 



countered in the rectus muscle. Rigidity of the right rectus alone 
occurs with acute appendicitis, whereas bi-lateral rigidity of the 
recti accompanies acute peritonitis. 

Tenderness. — When tenderness is elicited upon palpation of the 
surface of the abdomen, if not due to hyper-esthesia of the pari- 
etes, it points to a diseased abdominal organ. The tenderness is 
most apt to be encountered over the gall-bladder, stomach, spleen, 
kidney, appendix, and sigmoid flexure. In acute peritonitis there 
is general or diffuse tenderness. 

Fluid Wave. — In the presence of ascites a fluid wave can be 
demonstrated upon bi-manual palpation. In palpating for fluid 
in the peritoneal cavity, one hand of the examiner is applied flatly 



PALPATION OF ABDOMEN 



327 



over one lumbar region, while the opposite side of the abdomen 
is tapped with the other hand of the examiner, the finger-tips 
being used. An impulse or wave is thus created in the fluid, 
which is appreciable to the palpating hand. 

Fat Wave. — Excessive deposition of fat in the abdominal wall 




Fig. 183.— Various areas of significant point-tenderness. These are the areas to be 

investigated during the course of an abdominal examination. (From Crossen.) 



gives a wave upon bi-manual palpation closely simulating the fluid 
wave. To exclude such a fat wave during bi-manual palpation an 
assistant should apply the ulnar side of the hand to the median 
line of the abdomen while the examiner practices bi-manual pal- 
pation as in eliciting the fluid wave, when the fat wave is inter- 



328 



PHYSICAL DIAGNOSIS 




Fig. 184. — Trying for a fluid wave across the abdomen. (From Crossen.) 







X 




Fig. 185. — Differentiating a fat-wave from a fluid-wave. The fat-wave is stopped by 
the pressure in the median line. (From Crossen.) 

rupted by the intervention of the assistant's hand and is not trans- 
mitted to the palpating hand of the examiner. 

Intra-Abdominal Tumor.— An intra-abdominal tumor may be so 
large as to entirely fill the abdominal cavity ; but as a rule careful 
bi-manual palpation enables the examiner to determine its origin, 



PERCUSSION AND AUSCULTATION 329 

its size and shape, whether it is fixed or movable, and finally 
whether it moves with respiration. In examining for respiratory 
mobility of an intra-abdominal tumor the examiner should place 
both hands palms downward flal upon the abdomen, with the 
fingers directed toward the costal arch, while the patient is di- 
rected to breathe deeply. At the commencement of expiration, the 
finger-tips are pressed downward firmly and with uniform pres- 
sure, when the lower margin of the tumor or enlarged organ is 
encountered. The most commonly encountered movable ab- 
dominal tumor is a movable or displaced kidney; but tumors 
of the liver, spleen, or stomach, are movable with respiration. 

Peritoneal Friction Fremitus. — Upon palpating over the upper 
regions of the abdomen a friction fremitus analagous to pleural 
or pericardial friction fremitus is sometimes encountered. The 
vibration is produced by roughening of the peritoneal surfaces in 
peritonitis. This fremitus is most commonly encountered over 
the hypochondriac regions, in the presence of peritoneal involve- 
ment in the course of peri-hepatitis or perisplenitis. 

PERCUSSION 

In the examination of the abdomen ordinary mediate finger 
percussion may be employed, although in delimiting the various 
solid viscera and tumors of the abdomen auscultatory percussion 
is more serviceable and reliable. In general, the percussion note 
is tympanitic over the hollow abdominal viscera, changing to dull- 
ness and flatness over the solid organs. A similar flat note is 
elicited over solid intra-abdominal tumors and fluid in the peri- 
toneal cavity. 

During percussion of the abdomen the patient should assume 
the dorsal decubitus with the abdomen exposed. In outlining 
the borders of solid organs and tumors and in estimating the rela- 
tive tympanicity of the adjacent hollow viscera, auscultatory 
percussion, using a light percussion blow or a stroking movement 
upon the abdominal surface is most serviceable. 

The details of technic of outlining the various abdominal vis- 
cera are discussed in their appropriate sections. 

AUSCULTATION 

Auscultation is seldom employed in the examination of the 
abdomen and its viscera. Upon auscultation over the spleen or 



330 



PHYSICAL DIAGNOSIS 




7 




Fig. 186. — Ordinary percussion, which 
is usually rather superficial. (From Cros- 
sen.) 



Fig. 187. — Deep percussion. Notice how 
the left index finger is pressed into the ab- 
domen, so as to thin out the wall -and get 
closer to deep structures. (From Crossen.) 




Fig. 188. — Showing the lines ior mensuration. (From Crossen.) 



PERCUSSION AND AUSCULTATION 331 

liver a friction rub may occasionally be audible in presence of 
peri-splenitis or peri-hepatitis, due to peritoneal involvement. 
Similarly, in cases of aortic aneurism a valvular murmur may be 
detected by auscultation over the course of the vessel. In cases 
of suspected pregnancy, again, auscultation is available in the 
search for the fetal heart sound as well as the umbilical or uter- 
ine souffle. 

MENSURATION 

Mensuration is employed in determining the approximate di- 
mensions of intra-abdominal tumors. Successive mensuration 
is practiced to determine progressive enlargement of the abd >- 
men from tumor or ascites. In practicing mensuration of the ab- 
domen three measurements are commonly employed; one at the 
level of the umbilicus; one three inches above this point ; and a 
third a similar distance below the umbilicus. 



SECTION II 

SPECIAL EXAMINATION OF THE ABDOMINAL 

VISCEEA 



CHAPTER XXIII 
THE STOMACH, INTESTINES, AND PANCREAS 

EXAMINATION OF THE STOMACH 

Clinical Anatomy. — The stomach occupies the epigastric and 
left hypochondriac regions of the abdomen when the organ is 
normal. The cardiac orifice of the stomach is located behind the 
seventh left costal cartilage, at a point one inch from the sternum. 
The position of the pyloric orifice is somewhat variable, its site 
being modified by the condition of the stomach. When the stom- 
ach is empty it occupies the median line at a point midway be- 
tween the epi-sternal notch and the symphysis pubis. When the 
stomach is moderately distended the pylorus occupies a position 
approximately one inch to the right of the mid-line at the same 
level, this displacement to the right being increased to two or 
three inches in extreme distention of the organ. 

The fundus of the stomach is in contact with the inferior aspect 
of the diaphragm, behind and below the apex of the heart, in which 
position it extends as high as the sixth rib. The lesser curvature, 
the upper limit of the stomach, is covered by the left lobe of the 
liver, passing downward and to the right from the cardiac orifice 
to the pyloric orifice of the stomach. The greater curvature, the 
lower limit of the stomach, crosses the left costal arch at the level 
of the ninth costal cartilage, the most dependent point of the nor- 
mal organ being approximately two inches above the umbilicus. 

The anterior surface of the stomach, largely overlapped by the 
left lobe of the liver, lower border of the left lung, and left costal 
arch, is exposed to the anterior abdominal wall in a very limited 
portion of its extent. Traube's semilunar space, the area in which 

332 



KXA.MIXATI0X OF STOMACH 



333 



the anterior wall of the stomach is in direct contact with the anterior 
abdominal wall, affording upon percussion pure gastric tympany, 
is limited above by the left lobe of the liver and lower border of the 
left lung, and externally by the spleen. 

The posterior surface of the stomach, looks backward and down- 
ward, reposing in the so-called "stomach bed" formed of the 






A \ 




i 



Fig. 189. — The central upper abdomen. Showing in outline the liver and stomach and 
pancreas. (From Crossen.) 



transverse mesocolon, the pancreas, left kidney, and supra-renal 
capsule. 

Inspection. — The normal stomach produces no alteration in 
the normal contour of the abdomen; but in persons with diastasis 
of the recti the greater curvature of the stomach which is the 
seat of dilatation or gastrectasis will cast a shadow by oblique il- 



334 



PHYSICAL DIAGNOSIS 



Antrum cardiacum 



Incisure/ angitlari 




Pylorus 
Pyloric canal 
Sulcus intermedius 

Pyloric vestibule 

Fig. 190. — Anatomic subdivisions of 
stomach. 



iith Thoracic V. 



ist Lumbar V. 




Fig. 191. — Form and surface topography 
of empty stomach. (From Gray.) 




Fig. 192. — Musculature of the stomach. (From Gray.) 



lumination, which ascends and descends with the movements of 
respiration. In gastrectasis the greater curvature of the stomach 
occupies a very low position, often below the umbilicus. 



KXAMINATIOX OF STOMACH 



335 








Fig. 193. — Traube's semilunar space. (From Butler.) 




Fig. 194. — Palpation of the epigastrium. 



Iii gastroptosis the epigastrium is flattened with more or less 
prominence in the umbilical region. 

Visible peristalsis of the stomach is often present in cases of 



336 



PHYSICAL DIAGNOSIS 



pyloric obstruction, the waves being recognized as a vermicular 
movement upon the abdominal wall which travels from the left 
to the right and downward. 

Palpation. — In practicing palpation of the stomach, the patient 
should assume the dorsal decubitus with the head comfortably 
elevated by a pillow and the legs drawn up and properly sup- 
ported. The examiner, seated on the left side of the patient 
should apply the tips of the fingers of the right hand to the epi- 
gastrium, the fingers being separated and extended. 

Palpation of the stomach may reveal the presence of tender- 




Fig. 195. — Epigastric pressure point. (From Austin.) 



ness, confirm visible peristalsis, or a tumor of the stomach, or 
succussion sounds. 

Tenderness in the area of the stomach is usually due to gastritis, 
but may be a sign of gastric ulcer or carcinoma, in which latter 
event the tender point adjacent to the tenth dorsal vertebra will 
be present. 

A tumor of the stomach may occupy the anterior wall, the pos- 
terior wall, or the pylorus. A pyloric tumor is accompanied by 
visible peristalsis and in addition there is usually a palpable tu- 
mor at the pyloric orifice. The stomach is usually the seat of gas- 



EXAMINATION OF STOMACB 



337 



trectasis and upon proper examination reveals succession sounds. 
A tumor upon the anterior wall of the stomach may be palpable 
by ordinary methods; but a tumor of the posterior wall may be 
confused with such a tumor. To differentiate the site of the tu- 
mor, whether on the anterior or posterior Avail of the stomach 




Fig. 196. — Dorsal pressure point in gastric nicer, indicated at a. (From Austin. > 




Fig. 197. — Showing the region for tenderness or a mass from disease of the stomach 
or pancreas. (From Crossen.) 



338 PHYSICAL DIAGNOSIS 

the stomach may be filled with gas by the ingestion in solution of 
a drachm of sodium bicarbonate, to be followed immediately by 
the ingestion of a similar amount of tartaric acid. The two com- 
pounds generate carbon dioxide which distends the stomach. 
When so distended a tumor situated upon the posterior wall is 
not palpable. 

Succussion sounds arising in the stomach are elicited by palpat- 
ing the epigastrium with short pushing movements with the finger- 
tips, beginning below the greater curvature of the stomach and 
proceeding upward until this point is reached, when the splashing 
sounds will be audible. 

Glenard's Belt Sign. — In gastroptosis and gastrectasis, when the 
examiner standing behind the patient, places his hands upon the 
lower portion of the abdomen and lifts upward and backward, 
the patient with gastroptosis or gastrectasis experiences a^ sensa- 
tion of relief from the dragging sensation which accompanies these 
states. 

Percussion. — Percussion of the stomach is employed to deter- 
mine the size, shape, and position of the viscus. The results of the 
examination vary with the state of the organ, whether empty or 
distended with fluid or gas. Normal gastric tympany is only ob- 
tained in Traube's semilunar space, where the stomach is in ap- 
position with the anterior abdominal wall. The fundus of the 
stomach is determined with difficulty, owing to its situation be- 
neath the left costal arch. 

The boundaries between the stomach and the liver and the 
stomach and left lung, the upper limits of Traube's space, can be 
determined by mediate percussion from an area of frank gastric 
tympany in the center of this space toward the liver and lung 
respectively. To delineate the lower border of the stomach or 
greater curvature it is necessary to introduce fluid into the stom- 
ach, since otherwise the tympany of the colon and stomach could 
not be distinguished. Upon percussing upward under these con- 
ditions, the colonic tympany will give place to dullness, when the 
greater curvature is reached. 

But the size, shape, and position of the stomach are better de- 
termined by auscultatory percussion. In this method of examina- 
tion the chest-piece of the stethoscope is placed at the center of 
gastric tympany in Traube's space. The examiner delivers a 
few blows and fixes in his mind the character of the sound 
elicited. Without moving the position of the stethoscope he then 
begins at several points and percusses from several regions of the 



EXAMINATION OF SMALL INTESTINE 339 

abdomen toward the bell of the stethoscope. In each instance a 
change in the quality of the percussion note will indicate when 
the stomach border has been reached. 

An extension of gastric tympany beyond the normal limit up- 
ward indicates gaseous distention of the stomach, or it may be 
due to cirrhosis of the liver or fibroid change in the left lung; or 
it may be a sign of gastrectasis resulting from pyloric stenosis. 

Diminution of the area of normal gastric tympany may be due 
to enlargement of the liver or spleen, or left sided pleurisy with 
effusion, or cardiac obstruction. 

An hour-glass constriction of the stomach may be demonstrated 
by the introduction of water into the stomach; when, upon per- 
cussion over the viscus, it is observed that the stomach is not 
uniformly distended; but that the cardiac portion is distended, 
while the pyloric portion remains empty; and, moreover, that in 
a short time fluid passes into the pyloric portion, which in turn 
becomes distended. If, during this time, the stethoscope be ap- 
plied over the central portion of the stomach, it may be possible 
to hear the water gurgle through the constricted portion of the 
stomach. 

Auscultation. — Apart from eliciting succussion sounds, the sig- 
nificance of which has been mentioned in the section upon palpa- 
tion, auscultation of the stomach yields little diagnostic data. 



THE SMALL INTESTINE 

Clinical Anatomy. — The small intestine, the section of the gas- 
trointestinal tract extending from the pyloric orifice of the stom- 
ach to the junction with the large intestine at the ileo-cecal valve. 
lies within the frame formed by the course of the large intestine, 
slightly overlapping the ascending and descending colon, and ex- 
tending for a variable distance below the brim of the pelvis. The 
duodenum, the proximal 12 inches of the small intestine pursues a 
course resembling the letter "0" from the pylorus to the duodeno- 
jejunal flexure at the left of the second lumbar vertebra, em- 
bracing in its course the head of the pancreas and the common 
bile duct which empties its contents into this portion of the 
small intestine. The jejunum, the second division of the small 
intestine, comprising approximately 8 feet of the tube, lies in the 
umbilical and right and left lumbar regions, and is freely movable. 
The ileum, the distal 12 feet of the small intestine, which terminates 
at the ileo-cecal valve, lies in the umbilical, hypogastric, and lum- 



340 



PHYSICAL DIAGNOSIS 



bar regions, in which it is freely movable. Only the great omen- 
tum intervenes between the jejunum and ileum and the anterior 
abdominal wall. 

Inspection. — Visible peristalsis of the small intestine may be 
seen in obstruction of this portion of the alimentary tract. If the 
site of the obstruction is in the lower portion of the ilium the pe- 






/ 




4 



' / \ 



Fig. 198. — The left upper abdomen. The site of the spleen and of the splenic 
flexure of the colon, the organs in this region most commonly affected, are shown by 
the stippling. When normal, the spleen lies considerably higher in the abdominal 
cavity than is generally supposed. Its anterior projection is shown here in dotted out- 
line, with the lower end in contact with the splenic flexure of the colon. (From Crossen.) 



culiar "ladder pattern" is noted occupying the umbilical region. 
Palpation. — The coils of the normal small intestine are not 
palpable. But in patients with moderately thin abdominal wall, 
hard fecal lumps, scybala, enteroliths, or large gall-stones are 
occasionally palpable. A hard tumor palpable in the region of the 



EXAMINATION OF SMALL INTESTINE 



341 



small intestine may be malignant or may be the result of intussus- 
ception, volvulus, or fecal impaction. Or it may be the result of 
tabes mesenterica, due to matting of the omentum in tuberculous 

peritonitis. When an intestinal solid tumor pulsates, the patient 
should be placed in the knee-chest posture in order to determine 
whether the pulsation is transmitted to the tumor from the ab- 
dominal aorta. When palpation is practiced in this posture, the 
tumor falls away from the aorta, and the pulsation of this vessel 
is no longer imparted to the tumor. 

Percussion. — The normal intestine yields tympany upon per- 




Fig. 199. — The duodenum, its four parts marked a, b, c, d. The liver is lifted up; 
the greater part of the stomach is removed, broken lines indicating its former position. 
(Gray, after Testut.) 



cussion, the presence of dullness or flatness usually indicating 
a tumor. When the intestine is greatly distended with gas 
in peritonitis or intestinal obstruction the percussion note is 
slightly lowered in pitch, but, is still tympanitic. A similar note 
may be produced by the presence of a solid tumor surrounded by 
resonant intestine. 



"342 



PHYSICAL DIAGNOSIS 



Auscultation. — The gurgling sounds or borborygmi which are 
frequently audible in the intestine have no significance. But in 



Anterior 



Posterior 
Middle lamella of 

lamella of lumbar fascia, 

lumbar / 



fascia, 
lamella 0/ / 

lumbar fascia. 



LATISSIMUS 




Fig. 200. — Relations of large intestine to kidneys. (From Gray.) 



auscultation over a partial obstruction a gurgling sound may often 
be audible, which is due to the passage of fluid through the con- 
stricted lumen of the gut. 



EXAMINATION OF LARGE INTESTINE 



343 



EXAMINATION OF THE LARGE INTESTINE 

Clinical Anatomy.— The large intestine, comprising the cecum 
with the vermiform appendix, ascending colon, transverse colon, 
descending colon, and sigmoid flexure, is arranged in the form of 
a frame enclosing the coils of the small intestine on the right, 



" 



)\ 



Fig. 201. — The right lower abdomen. The organs commonly affected, and the areas 
accordingly of particular interest, are indicated by the stippling. (From Crossen.) 



superiorly, and upon the left. The cecum with the appendix 
occupies the right iliac and hypogastric regions. The ascending 
colon passes vertically upward in the right lumbar and right hypo- 
chondriac regions to the tenth right costal cartilage. The trans- 
verse colon passes across the abdomen, descending from the right 



344 



PHYSICAL DIAGNOSIS 




Fig. 202. — Indicating the point to seek for 
appendix tenderness. (From Crossen.) 



Fig. 203. — Palpating for tenderness or a 
mass in the appendix region. (From Cros- 
sen.) 





Fig. 204. — Palpating for the appendix 
itseif, to determine whether or not there is 
any appreciable infiltration and thickening 
of it. When thickened* the appendix is felt 
as a smali tender roll, deeply placed. (From 
Crossen.) 



Fig. 205. — Another method of palpating 
the appendix. Beginning near the umbili- 
cus, the fingers are carried in deeply and 
then brought slowly outward toward the 
anterior superior iliac spine. As the ap- 
pendix passes under the examining fingers, 
it is felt as a small roll between the fingers 
and the posterior abdominal wall. (From 
Crossen.) 



EXAMINATION OF LARGi; IXTKSTINE 



345 



hypochondriac region to the upper part of the umbilical region; 
thence ascending obliquely into the left hypochondriac region to 
the lower extremity of the spleen. The descending colon passes 
vertically downward in the left lumbar and iliac regions, ter- 
minating in the sigmoid flexure in the hypogastric region. 

Inspection. — In cases of gaseous distention of the large intestine 




•1 




Fig. 206.— -The left lower abdomen. The organs commonly affected, and the areas 
accordingly of particular interest, are indicated by the stippling. (From Crossen.) 

there is often a visible tumefaction in the right and left lumbar 
and in the hypogastric region, which corresponds with the course 
of the ascending and descending colon. Gaseous distention of the 
transverse colon is apt to produce a protrusion just above the 
umbilicus in the umbilical region. (See Figs. 159, p. 312.) 

Palpation. — In palpating the cecum the examiner, seated at the 



346 



PHYSICAL DIAGNOSIS 



right side of the patient applies the right hand over the gut and 
presses downward with a rolling movement, endeavoring in this 
manner to outline the gut. The gurgling murmur which is usually 
set up by this maneuver possesses little or no significance. During 
this examination an attempt should be made to palpate the vermi- 
form appendix, which is often to be felt along a line from Mc- 
Burney's point to the symphysis pubis as a cord about the size 
of a lead pencil, and about the length of the little finger. In this 
manner any tenderness or thickening of the appendix is to be de- 
termined if possible. 




Fig. 207. — Palpating for tenderness or a mass in the umbilical region. (From Crossen.) 



In palpating the ascending colon the patient should assume 
the left lateral decubitus, while the examiner applies the right 
hand to the abdomen at' right angles to the course of the colon 
and by means of a rolling movement determines whether 
the colon is contracted or distended, and whether it contains 
fecal masses. Fecal accumulation is more common in the cecum 
and ascending colon than elsewhere. As mentioned, gurgling is 
particularly common in the cecum with little significance. 



EXAMINATION OF LARGE INTESTINE 347 



* c 




Fig. 208. — Palpation of ascending colon. 




Fig. 209. — Palpation of the descending cok 



348 PHYSICAL DIAGNOSIS 

In palpating the transverse colon the patient lies upon the back 
while the examiner places both hands flat upon the abdomen in 
the umbilical region with the finger-tips extending somewhat 
above the umbilicus. The patient is instructed to breathe deeply 
and at the commencement of each expiration the examiner makes 
downward pressure with the finger-tips and endeavors to deter- 
mine the position and state of this portion of the intestine. In 
palpation of this portion of the colon, as in other portions, the 
hand should be applied at right angles to the course of the intes- 
tine. Therefore, if the transverse colon pursues an arched course 
with the convexity downward, as it frequently does, the right 
and left halves of this portion of the intestine must be palpated 
in different directions. While the normal transverse colon is 
found at or above the umbilicus, in enter opt osis it may be encoun- 
tered as low as the symphysis pubis. 

The descending colon is palpated with the patient in the right 
lateral decubitus, the method corresponding in all respects with 
that employed in palpating the ascending colon. 

Palpation of the sigmoid flexure is performed with the patient 
in the dorsal position, the examiner placing the fingers of the 
right hand upon the abdomen at right angles to the course of the 
gut, rolling the intestine between the finger-tips and the iliac 
fossa, searching for tenderness, muscular rigidity, tumor, or 
fecal impaction. As a rule, impacted feces will pit upon pres- 
sure, whereas a hard tumor will not. 

EXAMINATION OF THE PANCREAS 

Clinical Anatomy. — The pancreas is an elongated solid organ, 
comprising a head, neck, body, and tail, situated deeply in the 
epigastric region, its tail, however, extending into the left hypo- 
chondriac region. 

The pancreas measures approximately six inches in length and 
its location in the abdominal cavity corresponds to the level of 
the first and second lumbar vertebras. The head of the pancreas 
is encircled by the second and third portions of the duodenum, 
the common bile duct intervening between the two structures, 
while the tail extends toward the left and is in relation with the 
hilum of the spleen. 

The pancreas is covered anteriorly by the peritoneum of the 



EXAMINATION OF PANCREAS 349 

lesser sac, this surface being in relation with the posterior wall 
of the stomach, the transverse colon, and a few coils of the small 
intestine. Posteriorly the pancreas rests upon the abdominal 




Fig. 210. — Relations of pancreas to adjacent viscera. 

i, aorta; 2, inferior vena cava; 3, esophagus; 4, splenic artery; 5 and 6, uretus; RK, 

right kidney; LK, left kidney; D, duodenum; P, pancreas; S, spleen. 

aorta and inferior vena cava, the right erus of the diaphragm, 
the renal and portal veins, and the left kidney. 

The pancreas crosses the lower portion of the epigastric region 
three inches above the umbilicus. 



350 



PHYSICAL DIAGNOSIS 




Fig. 211. — Topographical relations of liver, bile passages, and pancreas. (From 

Fisendrath.) 

S, stomach in dotted outline; L, cut edge of right lobe of liver; PV, portal vein; 
As. V, ascending vena cava; DC, common duct; G, gall-bladder; Du, duodenum; Sp, 
spleen; RK, right kidney; LK, left kidney; Coe, celiac axis; A, aorta; CO, cardiac orifice 
of stomach; Di, diaphragm; P, pancreas; Py, pyloric end of stomach; V, duct of Wirsung, 
joining with common bile-duct; AW, accessory duct of Wirsung. 




Fig. 212. — Position and relations of pancreas. (From Gray.) 



EXAMINATION OF PANCREAS 



351 



Physical Examination. — Owing to the deep location of the pan- 
creas within the abdomen, physical examination of the organ is 
not very satisfactory, being limited to palpation. 

The normal pancreas is seldom palpable save in a very emaci- 
ated patient witli diastasis of the rectus muscles. 

When a mass is encountered in the deeper portion of the epi- 
gastric region it is apt to be a cyst or solid tumor of the pan- 
creas. Pancreatic tumors in the great majority of instances are 
carcinomata. 

A tumor arising from the pancreas may be mistaken for a 



SUP. MESENTERIC ARTERY. 




IREA FOR DIA 



Fig. 213.: — Pancreas and duodenum. Posterior view. (.From Gray.) 



tumor of the pylorus, a distended gall-bladder, aortic aneurism or 
a tumor of the transverse colon. A pyloric tumor is always more 
superficial than is a pancreatic growth. Moreover, a tumor at the 
pylorus is freely movable and produces pyloric stenosis with a 
consequent dilatation of the stomach. A distended gall-bladder 
exhibits lateral mobility, is more superficial than is a tumor of 
the pancreas, and is not accompanied by glycosuria and fatty 
stools as is a pancreatic new-growth. 

A pancreatic tumor may be raised with each pulsation of the 
aorta, simulating aortic aneurism; but while the pulsation of 
aortic aneurism is expansile and exerted in all directions, that of 



352 



PHYSICAL DIAGNOSIS 



an overlying pancreatic tumor is not, the mass merely being raised 
with each pulsation of the subjacent aorta. 

A tumor of the transverse colon is very near the surface of the 
abdomen, it is freely movable, is prone to cause constipation, and 
blood is frequently found in the stools with such growths. 






Fig. 214. — The right upper abdomen. The site of the gall-bladder, the area of 
particular interest in this region is indicated by the letters G.B. (From Crossen.) 



CHAPTER XXIV 
EXAMINATION OF THE LIVER AND GALL-BLADDER 

Clinical Anatomy. — The liver, the largest gland of the body, 
occupies the upper and right portion of the abdominal cavity, 
lying in the right hypochondriac region, a larger portion of the 
epigastric region, the thin extremity of the left lobe extending 
into the left hypochondriac region, and the lower extremity of 
the right lobe invading the right lumbar region for a short dis- 
tance. The liver is roughly wedge-shaped, with the wide base di- 
rected toward the right, and the thin sharp edge of the wedge 
directed toward the left side of the abdomen. The normal adult 
liver measures eight to nine inches transversely, six to seven 
inches vertically at the base of the wedge, and four to five inches 
antero-posteriorly at a point on a level with the upper border 
of the right kidney. (See Fig. 214, p. 352.) 

The liver is divided into two unequal portions, the right and left 
lobes, by the falciform ligamenl and longitudinal fissure, the 
right lobe greatly exceeding the left lobe in size. At the point 
where the falciform ligament joins the inferior margin of the 
liver there is a small notch, the umbilical notch, which is situated 
at the level of the ninth right costal cartilage one inch to the 
right of the median line. Slightly beyond this notch the liver 
presents a second notch in which is lodged the fundus of the gall- 
bladder, corresponding to the junction of the ninth rib and the 
right border of the rectus muscle. (See Fig. 149, p. 300.) 

The upper surface of the liver, smooth and convex, is closely ap- 
plied to the concave under surface of the diaphragm. Upon its 
central portion the superior surface of the liver presents a shallow 
depression, the cardiac depression, corresponding to the position 
of the heart upon the upper surface of the diaphragm. 

The anterior surface of the liver is applied to the under surface 
of the diaphragm which separates it from the lower ribs and their 
cartilages upon the right and left sides, while in the median line 
it comes into direct contact with the anterior abdominal wall in the 
costal angle. 

The right and posterior surfaces of the liver are in contact with 

353 



354 



PHYSICAL DIAGNOSIS 



the under surface of the diaphragm, which separates the liver from 
the right pleural cavity and lower border of the lung. 

The under surface of the liver, directed backward and toward 
the left, is in relation with the stomach, the hepatic flexure of the 
colon, the right kidney and supra-renal, the second portion of the 
duodenum and the gall-bladder. 



Gallbladder. 




BIGHT LATERAL 
LIGAMENT. 



IEFT LATERAL 
LIGAMENT. 



Fig. 215. — Superior surface of liver. (From Gray.) 



uprarcnal 
impression 
{non- peritoneal). 




Tuberculnvf 
papillaif 



Umbilical, fissure. 



Transverse fissure. 



Fig. 216. — Inferior surface of liver. (From Gray.) 



Surface Topography. — The upper border of the liver corre- 
sponds to the level of the lower border of the sixth rib in the mid- 
clavicular line, the lower border of the eighth rib in the mid- 
axillary line, and the lower border of the tenth rib in the scapular 
line. 



EXAMINATION OF LIVER AND GALL-BLADDER 



355 



The lower border of the liver corresponds to a line drawn down- 
ward and to the right from the lower border of the sixth rib in 
the left mid-clavicular line, the point on the surface corresponding 
to the left extremity of the organ, the line crossing the left costal 
arch at the eighth costal cartilage, the median line four inches be- 
low the ensiform cartilage, the right costal arch at the ninth costal 
cartilage, the lower border of the tenth rib in the mid-axillary line, 
and the lower border of the eleventh rib in the scapular line. 

Inspection. — Enlargement of the liver produces prominence 
of the right costal margin and fullness in the right hypochondriac 
and epigastric regions. Rarely it is possible to perceive the Lower 



DIAPHRAGMATIC 
GROOV 




Fig. 21! 



-Corset liver. (From Gray.) 



border of the enlarged liver rise and fall Avith the respiratory 
movements. A small local enlargement of the lower portion of 
the liver is more readily perceived by inspection than is a mod- 
erate symmetrical enlargement. As a rule, in examination of 
the liver inspection is inferior to palpation, impressions based 
upon inspected signs alone often leading to error. (See Fig. 
220, p. 357.) 

Systolic pulsation of the liver is occasionally visible in tri- 
cuspid regurgitation, though usually the pulsation requires bi- 
manual palpation for its recognition. A transmitted impulse 



356 



PHYSICAL DIAGNOSIS 




Fig. 218. — Indicating the site for tenderness or a mass due to disease of the gall- 
bladder. It may be found anywhere from the point indicated downward and outward 
to the margin of the ribs on the right side. (From Crossen.) 




Fig. 219.— Palpation of liver. 



EXAMINATION OF LIVER AND GALL-BLADDLk 



357 



conveyed to the liver by the impact of an over-acting heart should 
not be mistaken for a true pulsation of the organ. 

Palpation. — Technic. — The patient should assume the dorsal 
decubitus with the knees drawn up and supported. The examiner, 
seated by the right side of the patient, should feel with the finger- 
tips of the right hand for the lower margin of the liver just be- 
low the lower costal margin. If it be found that the liver pro- 




Fig. 220. — Hepatic enlargement due to carcinoma of head of pancreas. R, right lobe of 
liver; L, left lobe of liver; G, distended gall-bladder. (From Eisendrath.) 

jects below the costal margin, the examiner places both hands flat 
upon the abdomen and by downward pressure causes the finger- 
tips to glide over the exposed portion of the liver, searching for 
any abnormality in contour. 

If the lower margin of the liver is not encountered below the 
costal margin, the examiner should place the finger-tips of both 
hands just below the costal arch and press inward as far as pos- 
sible. The patient is directed to inspire deeply, when during in- 



358 



PHYSICAL DIAGNOSIS 



spiration the liver will be felt to descend with the descent of the 
diaphragm and become palpable at the completion of inspiration. 

By the first maneuver an enlarged liver will be revealed pro- 
jecting below the costal arch ; while, by the second maneuver a 
normal or contracted liver may be palpated. 

Tenderness npon palpation of the liver may arise from disease 
of the liver or gall-bladder. Hepatic tenderness is present in 
hepatic congestion, peri-hepatitis, acute yellow atrophy, and hyper- 
trophic biliary cirrhosis. Cholecystitis and cholelithiasis are at- 
tended by tenderness having its point of maximum intensity at 




Fig. 221. — Dorsal pressure point in chololithiasis. (From Austin.) 

the junction of the ninth costal cartilage and the outer border of 
the right rectus muscle. 

Systolic Pulsation of the liver, recognized by bi-manual palpa- 
tion of the liver is a sign of tricuspid regurgitation. 

Enlargement of the liver accompanies fatty infiltration of the 
organ, chronic passive congestion of the organ and amyloid dis- 
ease of the liver; Weil's disease, hepatic abscess, carcinoma or 
gumma or leukemia, and hypertrophic cirrhosis, echinococcus cyst 
or Baud's disease, or acute infectious fevers. 

Keidel's lobe, a congenital anomaly of the liver, sometimes palp- 
able below the right costal arch as well as a similar deformity of 
the liver incident to prolonged tight lacing in female subjects, 



EXAMINATION OF LIVLR AND GALL-BLADDER 



359 



may be mistaken for a tumor of the liver. But when a tumor is 
suspected it should be borne in mincl that the liver comes third 
in the order of frequency as the site of abdominal carcinomata. 
Carcinoma of the liver produces considerable degree of enlarge- 
ment of the organ, often associated with carcinomatous nodules 
projecting from the surface of the organ. These nodules are 
hard and often umbilicated. 

A kidney enlarged as the result of hydro-nephrosis, tubercu- 
losis, or malignant disease, may be mistaken for an enlargement 
of the liver. In this connection the examiner should remember 
that the enlargements springing from the kidney occupy a more 



f 




555\_ 


lUta 


39 

3 


J 


k 


\ 


! v 



Fig. 222. — Palpating for general tenderness 
of the liver. (From Crossen.) 




Fig. 223. — Showing the site for tender- 
ness of the left lobe of the liver. (From 
Crossen.) 



lateral position in the abdomen; also that the hepatic flexure of 
the colon is united to the lower pole of the kidney with the re- 
sult that when the kidney enlarges it carries the colon in front 
of it, whereas an enlargement of the liver descends in front of 
the hepatic flexure, the colon lying external to the tumor. (See 
Fig. 200, p. 342.) 

Percussion. — While palpation reveals the presence of localized 
enlargements of the liver and of the organ as a whole, percussion 
is usually more serviceable in determination of changes in the 
size of the organ and displacements. 

The Areas of Hepatic Dullness and Flatness.— Upon percussing 



360 PHYSICAL DIAGNOSIS 

downward over the surface of the thorax and abdomen in the 
mid-clavicular, mid-axillary, and scapular lines from an area of 
frank vesicular resonance, the percussion note will become im- 
paired or dull when the point is reached where the upper limit 
of the liver is overlaid by the pulmonary structures. The point 
of change in the note indicates the upper limits of the area of 
hepatic dullness. The upper limits of this area are encountered 
in the fourth interspace in the mid-clavicular line, the seventh 
interspace in the mid-axillary line, and at the eighth interspace 
in the scapular line. (See Fig. 100, p. 213.) 

Upon continuing the percussion downward along these lines, 
substituting light for forcible percussion a point is reached in 




_u:i; 



Fig. 224. — Indicating the region for dullness from enlarged liver. (From Crossen.) 

which the dullness gives place to flatness, indicating the upper 
limit of the region where the liver is in direct contact with the 
adbominal wall, the upper limit of the area of hepatic flatness. 
The upper limits of this area are found in the normal subject at 
the sixth rib in the mid-clavicular line, the eighth rib in th6 mid- 
axillary line, and the tenth rib in the scapular line. 

If the percussion is continued downward along the same lines 
the flat note will be replaced by intestinal tympany when the 
lower limit of the liver is attained. The points of change indi- 
cating the lower limit of the area of hepatic dullness are en- 
countered at the ninth rib in the mid-clavicular line, the tenth 
rib in the mid-axillary line, while in the scapular line the flat- 
ness of the liver is continuous with that produced by the kidney. 



EXAMINATION OF LIVER AND GALL-BLADDER 361 

The lower limit of the area of hepatic flatness in the epigastric 
region lies three inches below the ensiform cartilage. Thus, it is 
observed that the area of hepatic dullness and flatness extends 
across the right upper portion of the abdomen, in a direction 
downward and toward the right; that posteriorly it is contin- 
uous with the flatness of the right kidney; and that anteriorly it 
blends with the right border of the area of cardiac flatness. 

Enlargement of the Liver, the principal causes of which have 
been detailed under palpation, is indicated by an extension of 
the area of hepatic dullness in one or more directions. An ap- 
parent enlargement of the hepatic area or an apparent increase 
in the area of hepatic dullness may be caused by enlargement of 
the right heart, a right sided pleural effusion or sub-phrenic 
abscess. 

Decrease of the Size of the Liver, occurring in atrophic cir- 
rhosis or acute yellow atrophy is indicated by a decrease in the 
extent of the area of hepatic dullness upon percussion. An ap- 
parent decrease in the size of the liver may be caused by hyper- 
trophic emphysema encroaching upon the hepatic area superiorly 
or by coils of the intestine in tympanites encroaching upon the 
area inferiorly. 

Displacement of the Liver 

Downward Displacement of the liver or hepatoptosis may be oc- 
casioned by the pressure upon the upper diaphragmatic surface 
by hypertrophic emphysema, pneumothorax, right sided pleurisy 
with effusion, cardiac hypertrophy or pericardial effusion. The 
liver may be pressed downward by a sub-phrenic abscess. Final- 
ly, the liver may participate in a general visceroptosis and occupy 
a lower level in the abdominal cavity than is normal. Down- 
ward displacement of the liver is separated from increased size 
of the organ by demonstrating by percussion that the upper limit 
of hepatic dullness occupies a lower level than is normal. 

Upward Displacement of the liver occurs as a result of pres- 
sure exerted upon the under surface of the organ by ascites, 
tympanites or abdominal tumor. Upward displacement may, 
however, be the sequence of decreased intra-thoracic pressure as 
occurs with fibroid retraction of the right lung ; or may be the 



362 PHYSICAL DIAGNOSIS 

result of paralysis of the diaphragm. In upward displacement 
of the liver it may be demonstrated by percussion that both the 
upper and lower limits of hepatic dullness are elevated, not the 
upper limit alone. 

Auscultation. — Auscultation over the hepatic area may elicit 
occasionally a friction sound in connection with peritoneal in- 
volvement in peri-hepatitis. In cases of cholelithiasis, gall-stone 
crepitations have been described. 



CHAPTER XXV 

EXAMINATION OF THE SPL*EEN, KIDNEYS, BLADDER, 

AND URETERS 

EXAMINATION OF THE SPLEEN 

Clinical Anatomy. — The spleen is a solid organ situated deeply 
in the left hypochondriac region, its upper and inner extremity 
crossing the left mid-clavicular line into the epigastric region. 
It is placed obliquely in the abdominal cavity, between the 
fundus of the stomach and the left kidney and diaphragm, its 
long axis corresponding to the course of the tenth rib. The 
spleen moves with the movements of respiration. (See Fig. 210, 
p. 349.) 

The spleen is separated by the diaphragm from the ninth, tenth, 
and eleventh ribs. The pleural cavity intervenes between the 
portion of the organ in contact with the diaphragm and the chest 
wall. The upper portion of the spleen also has the lower border 
of the left lung overlying it. The spleen measures five inches 
in its longest diameter, and three inches in width. 

The spleen corresponds to an area on the surface of the body 
from the ninth to the eleventh ribs, inclusive, its inner end be- 
ing one and one-half inches from the mid-spinal line, its outer 
end reaching as far forward as the mid-axillary line. 

Inspection. — The normal spleen gives no visible signs of its 
presence. When enlarged it produces bulging of the abdominal 
Avail in the right hypochondriac and epigastric regions, which 
may be moderate, or as in the case of the leukemic spleen, may 
be extreme. 

Palpation. — Technic. — With the patient in the dorsal decubitus 
the examiner should apply the hand flat upon the abdomen so that 
the finger-tips can be inserted beneath the left costal arch. If the 
spleen is enlarged, no difficulty will be experienced in palpating 
the lower border. However, the normal organ is not palpable. 
If the spleen is not encountered by the procedure described, the 
patient is directed to inspire deeply. L'pon making pressure at the 
commencement of full inspiration the lower border of the organ 

363 



364 



PHYSICAL DIAGNOSIS 



will be felt as it descends with the diaphragm during respiration. 
Some difficulty may arise in determining whether a palpable 
tumor below the left costal arch is the spleen or kidney. In this 
connection it should be recalled that the spleen moves with res- 
piration whereas the kidney does not. Moreover, the kidney is 
overlapped by the large intestine, an enlargement of the kidney 
pushing the tympanitic gut before it, whereas the spleen occupies 
a position in front of the intestine. Finally, the shape of the two 




Fig. 225. — Indicating the area to search for splenic tenderness or enlargement. 
When the spleen is diseased it usually becomes enlarged and heavy and sinks below 
the margin of the ribs at the point indicated. (From Crossen.) 



organs differs, the spleen being more or less tetrahedral with a 
sharp edge, while the kidney is smooth and reniform. 

Aside from leukemia, splenic enlargement occurs in the course 
of many acute infections, in cirrhosis of the liver, and Banti's 
disease, and when the seat of a tumor. The organ is also enlarged 
in acute splenitis, in which the area of splenic dullness extends 
rapidly, accompanied by local pain and tenderness. In chronic 



EXAMINATION OF THE SPLEEN 



365 



malaria the spleen is enlarged, constituting the "ague-cake" of 
this condition. Amyloid infiltration produces symmetrical enlarge- 
ment of the spleen, of firm consistence. In movable spleen the 
organ is first larger than normal, and later small. 



4 



Fig. 226. — Indicating the region for dullness from enlarged spleen. (From Crossen.) 




Fig. 277. — Palpation of the spleen. 



Tenderness on palpation of the spleen may be due to acute 
congestion, peri-splenitis, or infarction of this organ. Signorelli's 



366 



PHYSICAL DIAGNOSIS 



Point, to which pain is referred in splenic disease is situated just 
below the junction of the fifth left costal cartilage and the mid- 
clavicular line. 

Downward Displacement of the spleen may be caused by in- 
creased sub-phrenic pressure by emphysema, left sided pneumo- 
thorax or pleural effusion, massive pericardial effusion, or tho- 
racic neoplasm. The spleen may drop downward owing to relax- 
ation of its ligaments, constituting the so-called movable or wan- 
dering spleen, which may be encountered in the pelvis. If the 
pedicle becomes twisted, the spleen becomes enlarged and later 
contracts, becoming smaller than the normal organ. The spleen 
also occupies a lower level than normal in Glenard's disease. A 




Fig. 228. — Splenic enlargement in leukemia. 

floating or movable spleen should not be mistaken for an abdom- 
inal tumor. The shape of the spleen, if it is possible to palpate 
it accurately, the presence of the notch, and its absence from its 
normal position as indicated by resonance in the splenic area, aid 
in differentating it from tumor. 

Upward displacement of the spleen occurs when it is pressed upon 
by ascites, tympanites, or large abdominal tumor. Fibroid retrac- 
tion of the left lung or paralysis of the diaphragm will cause it 
to occupy a higher level in the abdominal cavity than is normal. 

Percussion. — In percussion of the spleen the patient may lie 
upon the right side, stand, or sit. To delineate the superior and 
inferior borders of the organ the examiner percusses downward 
from the area of frank pulmonary resonance in the axillary re- 



EXAMINATION OF Till! KIDNEYS 367 

gion, until the dulling of the note indicates that the upper border 
of the spleen has been reached. Upon continuing the percussion 
downward, the dullness will give place to the intestinal tympany 
when the lower border is reached. The anterior border is lo- 
cated by percussing outward from the median line in the tenth 
intercostal space. The posterior border is defined by means of 
percussion carried outward from the left side of the vertebral 
column. In delimiting the spleen light percussion is necessary on 
account of the proximity of the organ to the stomach and colon, 
which serve to add a tympanitic quality to the note elicited upon 
forcible percussion. 

Percussion of the spleen confirms the palpatory signs as to en- 
largement and displacement of the organ. As in the case of other 
solid organs auscultatory percussion may be employed to ad- 
vantage in outlining the position of the spleen. 

Auscultation yields little data concerning the spleen, except to 
determine a friction sound in cases of peri-splenitis. 

EXAMINATION OF THE KIDNEYS 

Clinical Anatomy. — The kidneys are situated in the posterior 
portion of the abdomen, behind the peritoneum, on either side of 
the vertebral column. The upper extremities of the kidneys cor- 
respond to the level of the upper border of the twelfth dorsal 
vertebra; the lower extremities are on a level with tin 1 third lumbar 
vertebra. Owing to its relation with the right lobe of the liver. 
the right kidney occupies a slightly Lower level than does the 
left. 

The kidney is approximately four and a half inches in length, 
two and a half inches in width, and two inches in thickness. The 
left kidney is somewhat longer and narrower than is the right. 

Posteriorly the kidneys rest upon the muscles of the pos- 
terior abdominal Avail, the psoas, quadratus lumborum, fascia of 
the transversalis, and the diaphragm. The anterior surface of 
the right kidnej^ is in relation with the visceral aspect of the liver, 
the descending portion of the duodenum, and the hepatic flexure 
of the colon and adrenal. The anterior surface of the left kid- 
ney is in relation with the posterior surface of the stomach, the 
spleen, the body of the pancreas, the jejunum, adrenal and splenic 
flexure of the colon. 

The kidneys are located in the epigastric, umbilical, and hypo- 
chondriac and lumbar regions on either side. The superior pole 



368 PHYSICAL DIAGNOSIS 

extends as high in the epigastric region as a transverse line drawn 
about two inches below the ensiform process. The inferior pole 
extends below the sub-costal line, only slightly in the case of the 
left ; and to a greater degree in the case of the right kidney. 

In the female subject the kidneys are placed lower than they 
are in the male. In both sexes the upper pole is nearer the mid- 




Fig. 229. — Surface markings of kidneys, uterus, and abdominal vessels. Anterior view. 

(From Eisendrath.) 

/, inferior vena cava; 2, aorta — celiac axis just below 2; 3 and 4, right and left renal 
veins; 5 and 6, right and left renal arteries; 7 and 8, right and leit ureter; Q, left 
spermatic vein; 10, right spermatic vein; 11, superior mesenteric artery; 12 and 
13, right and left spermatic arteries; 14, external iliac arteries; 15, external iliac veins; 
RK, right kidney; LK, left kidney; SP, spleen. 



EXAMINATION OF THE KIDNEYS 369 

die line than is the inferior. In the infant the kidneys are rel- 
atively larger than in the adult. The relative weight of the 
kidney in the adult to the entire body weight is 1:240, whereas 
in the infant it is 1:120. 



Fig. 230. — Surface markings of pleura, lungs, interlobar fissures, and relations of 
pleural cavities to kidneys. (From Eisendrath.) 
I, apical and mediastinal pleura; 2, upper and posterior margins of lungs; 3, 
interlobar fissure between upper and lower lobes on each side; 4, lower border of lung; 
5, lower border of pleura; 6, left kidney; 7, right kidney; 8, descending colon; 0, trans- 
verse colon; jo, ascending colon; 11 and 12, sigmoid flexure; 13, rectum and anal 
canal; 14, cecum; 15, termination of ileum; 16, appendix; DS, left dome of diaphragm; 
DR, right dome of diaphragm; SP, spleen. 



370 PHYSICAL DIAGNOSIS 

Inspection. — The normal kidney yields no evidence of its pres- 
ence on inspection. However, tumors of the organ, hydronephro- 
sis, or large cystic kidney produces bulging in the umbilical and 
lumbar regions. The costal arch is pressed forward. The mass 
does not move with the movements of respiration. It is to be re- 
membered that a tumor of the kidney in a child is probably sar- 
coma. Peri-nephric abscess may produce bulging in the costo- 
vertebral angle posteriorly. Concomitant signs are edema of the 
skin, and the presence of fluctuation with septic symptoms. 

Palpation. — Technic. — The patient assumes the dorsal decubi- 




Fig. 231. — Palpation of the kidney. 

tus, with the knees drawn up and supported, the arms hanging 
loosely at the sides. 

The examiner sits by the side to be examined. Bi-manual pal- 
pation is employed. The examiner makes pressure with the in- 
dex and middle fingers of the left hand in the costo-vertebral 
angle, the interval just below the twelfth rib near the spinal 
column. The examiner places his right hand upon the anterior 
abdominal wall one inch external to the linea semilunaris, his 
fingers directed upward, just below the costal arch. The patient 
breathing deeply, the examiner makes downward pressure with 
the fingers of the right hand, at the same time making pressure 



EXAMINATION OF THE KIDNEYS 



371 




Fig. 232. — Indicating the region for kidney tenderness in front, on the right side. 
(From CrossenJ 




Fig. 233. — The point for kidney tenderness laterally. (From Crossen.) 



372 



PHYSICAL DIAGNOSIS 




Fig. 234. — The point for kidney tenderness posteriorly. (From Crossen.) 




Fig. 235. — The area for left kidney tenderness in front. (From Crossen.) 



EXAMINATION OF THE KIDNEYS 



373 



with the left. If in this manner the kidney be felt at the comple- 
tion of inspiration, but glides back into place during expiration 
the condition constitutes movable kidney. 

Three degrees of movable kidney are recognized. In the first 
degree, only the lower pole of the kidney is palpable; in the second 
degree the lower half of the kidney is palpable; Avhile in the 
third degree the entire organ can be palpated. 

If, on the contrary, the kidney fails to glide back into its normal 
position during expiration, it' during this period the entire kidney 
remain palpable, and can be pushed about in the abdominal cav- 




Fig. 236. — Method of palpating for a mass in the kidney region. The structures are 
caught between the hand behind and the one in front. (.From Crossen.) 



ity, the condition is termed a displaced kidney, or floating kidney. 

The right kidney is frequently movable in girls and women, 
particularly in those with enteroptosis ; less frequently movable 
in men. 

While the normal kidney is palpated with difficulty, and often 
is not palpable, a kidney enlarged by malignant disease is readily 
palpated. A kidney the seat of hydro-nephrosis, pyelo-nephrosis, 
and surgical kidney, often yields fluctuation on bi-manual pal- 
pation. 



374 



PHYSICAL DIAGNOSIS 




Fig. 237. — Point for kidney tenderness laterally. (From Crossen.) 




Fig. 238. — -Points for kidney tenderness in the back. (From Crossen.) 



EXAMINATION OF THE KIDNEYS 375 

When a mass is felt in this region doubt may arise as to 
whether or not it is an enlarged kidney or whether it is a gall- 
bladder or spleen, or pancreatic in origin, or of the pylorus. A 
tumor of the kidney is situated more laterally than a distended 
gall-bladder, and shows its radius of mobility is backward into the 
loin, while that of the gall-bladder is transversely below the mar- 
gin of the liver. As stated in a previous section, the hepatic 
flexure of the colon is attached by areolar tissue to the loAver 
extremity of the right kidney so that a renal enlargement or tu- 
mor carries the tympanitic colon before it, while tumors of the 
gall-bladder, pylorus, or pancreas reach the abdominal Avail nearer 
the median line, without the intervention of the tympanitic 
colon. 

In the case of the left kidney, bow ever, owing to the fact that 




Fig. 239. — Relation of the kidney to the lower margin of the last rib. (Crossen, after 

Butler.) 

there is no attachment to the splenic flexure, the colon is pushed 
internally, allowing a renal tumor to meet the abdominal Avail. 
However, the displaced colon will yield a tympanitic note along 
the inner border of the solid mass. 

Tumors or enlargements of the spleen approach the abdominal 
wall above the transverse colon, Avhich is displaced downward. 

A poly-eystie kidney is studded with roundish masses, which may 
be appreciated by palpation. 

Malignant tumors of the kidney deA T elop anteriorly, Avhere they 
form palpable tumors, Avhereas a peri-nephric abscess is most 
plainly palpable posteriorly. 

If palpation of the kidney yields no enlargement of the organ, 
but tenderness oA^er the renal area, renal inflammation or inflam- 



376 



PHYSICAL DIAGNOSIS 




pj g> 240. — Showing technic of physical examination for nephroptosis. First position of 
examiner's hands in both positions of the patient. (From Longyear.) 




Fig 241. — Showing technic of physical examination for nephroptosis. Second position 
of examiner's hands in both positions of the patient. The kidney is held in ptosis by 
deep pressure of the thumb under the costal margin and palpated by the tips of the 
fingers of the left hand. (From Longyear.) 



EXAMINATION OF THE BLADDER 377 

inatioii of the surrounding structures may be assumed to be 
present. 

In certain cases of movable or wandering kidney, the kidney 
may be more readily palpated Avith the patient in the sitting 
posture. 

Percussion. — In examination of the kidney percussion is much 
inferior to palpation. The normal kidney cannot be mapped out 
anteriorly; but posteriorly the inferior pole and outer eon vex 
border can be marked out from the tympanitic colon which sur- 
rounds it, the upper limit of dullness blending with that of the 
liver or spleen. 

When, however, the kidney is much enlarged from tumor or 
other cause, so that the organ approaches the anterior and Lateral 
abdominal vails, percussion is useful in delineating the bound- 
aries of the enlarged organ; bul even in this event percussion is 
inferior to skillful and careful palpation. Floating kidney may 
be indicated by the presence of tympany in the renal area where the 
note should be dull. 



EXAMINATION OF THE BLADDER 

The bladder is a hollow viscus, lying posterior to the symphysis 
pubis. A pelvic organ in the adult, in the infant the bladder is 

situated in the abdominal cavity above the pubic symphysis. 

Inspection. — The normal bladder is not visible: but when dis- 
tended it produces bulging in the hypogastric region which, in 
extreme cases, may extend into the umbilical region. The cause 
of such distention may be prostatic hypertrophy, a lumbar cord 
lesion, or the comatose state of an acute infection. 

Palpation. — The moderately distended bladder cannot be pal- 
pated through the abdominal wall; when, however, distended 
fully, it may be felt as a tense spherical mass in the hypogastric 
region. 

Percussion. — Percussion is only available in cases of extreme 
distention, when a flat note in elicited surrounded by intestinal 
tympany. 

Auscultation is not employed in the physical examination of 
the bladder. 



378 



PHYSICAL DIAGNOSIS 



EXAMINATION OF THE URETERS 

The normal ureter cannot be palpated, and an enlarged one 
only in an emaciated subject with very lax abdominal walls. 
However, palpation over the ureter may elicit tenderness due to 
inflammation of the tube, which on the right side must not be 
mistaken for inflammatory disease of the vermiform appendix or 
gall-bladder. (See Fig. 229, p. 368.) 




Fig. 242. — Indicating the site to searcti Fig. 243. — Palpating for tenderness or 

for tenderness of the right ureter. This thickening about the right ureter. (From 
may be found anywhere from the point Crossen.) 
indicated to some distance inside the circle, 
towards the umbilicus. (From Crossen.) 



The course of the ureter is indicated on the surface of the 
abdomen by a line drawn almost vertically from a point in the 
umbilical region about two inches from the median line at the 
level of the anterior extremity of the twelfth rib to a point a 
little below the umbilicus, thence converging toward the median 
line as the symphysis pubis is approached. 



PART III. THE HEAD, NECK AND EXTREMITIES 



SECTION I 
THE HEAD AND NECK 



CHAPTER XXVI 

EXAMINATION OF THE HEAD 

In the examination of the head the following points should be 
noted by the examiner: 

1. Size and shape. 

2. Condition of the fontanelles 

and sutures (in children). 

3. Condition of the bones. 

4. Condition of the hair. 

5. Position of the head. 

6. Movements of the head. 

Size and Shape. — The head may be abnormally small (micro- 
cephalia) with premature closure of the fontanelles and sutures, 
a condition usually associated with idiocy. 

A very large head is encountered in hydrocephalus, while mod- 
erate enlargement occurs in connection with rickets and cretin- 
ism and hypertrophia cerebri. 

In rickets the circumference of the head is increased two or three 
inches, the enlargement being chiefly due to thickening of the 
cranial bones. The shape of the head is rather square (box head), 
owing to the presence of osteoid bosses upon the frontal and 
parietal regions. The rachitic head is flattened at the vertex and 
over the occiput. Soft, compressible areas, craneotabes, are often 
present ; the fontanelles are widely open and the sutures are tardy 
in closing. 

Concomitant signs of rickets are the rosary, the chicken or pigeon 
breast, spinal curvature, tumid belly, and changes in the extremi- 
ties of the long bones. 

379 



380 PHYSICAL DIAGNOSIS 

Hydrocephalic Head. — In hydrocephalus the head is enlarged, 
the circumference sometimes reaching 32 inches at the eighth 
month of life. The large prominent forehead is in marked con- 
trast with the small face. The fontanelles and sutnres are widely 
open, and the veins of the scalp are prominent and distended. 
The skull is very thin and may be translucent to candle light. 
The child has difficulty in holding the head up. 

While the head in hydrocephalus somewhat resembles the ra- 
chitic head, there are differences. In hydrocephalus the shape is 
globular rather than square as in rickets; also in hydrocephalus 
the sutures and fontanelles are wider and the fontanelles bulge, 
which is not true of rickets. 

In cretinism the head is large, flattened at the vertex, with open 
sutures and fontanelles, but without bulging. The facial expression 
is dull, the nose flat, the face large, with puffy eyelids. The ex- 
tremities are short and thick; the tongue is large, often protruding 
from the mouth. There are pads of fat in the supra-clavicular 
regions. 

Fontanelles and Sutures. — The posterior fontanelle normally 
closes about the end of the second month, while the anterior fon- 
tanelle closes between the eighteenth and twentieth months of 
life. 

Tardy closure of the fontanelles occurs most frequently in con- 
nection with rickets. Closure is also delayed' in hydrocephalus 
and cretinism. In rickets the fontanelles may remain open beyond 
the fourth year of life. 

Bulging fontanelles indicate increased intra-cranial pressure, and 
are noted in hydrocephalus, cerebral hemorrhage, meningitis, brain 
tumor, sinus thrombosis, meningeal hemorrhage, and during acute 
fevers. 

Depressed fontanelles are noted during chronic wasting diseases, 
in pulmonary diseases attended by dyspnea, after severe diarrhea, 
during the early stages of meningitis, and in cholera infantum. 

Enlargement of the fontanelles, the anterior fontanelle exceeding 
one inch in diameter, is suggestive of rickets, hydrocephalus, cre- 
tinism, and may be a hereditary condition. 

Open Sutures. — The sutures of the child's head normally close 
between the sixth and eighth months. Open sutures after this 
time are significant of rickets, cretinism, or hydrocephalus. 

Condition of the Bones of the Head. — A number of changes in 
the bones of the head possess diagnostic significance. 



EXAMINATION OF THE HEAD 381 

Craniotabes, the presence of thin, compressible areas in the 
cranial bones, is symptomatic of rickets, infantile syphilis, or chon- 
drodystrophy. 

Osteoid bosses on the frontal and parietal bones in infants are 
symptomatic of rickets. 

Soft, nodular swellings on the skull, which become harder with 
advancing age, are symptomatic of syphilitic periostitis of the cra- 
nial bones. 



See E 


v *^B 


1 ■ 


3R ^ 




f 


^^' 


JH 


♦ 


1 



Fig. 244. — Alopecia areata. Numerous small patches have coalesced, forming a 
rather unusual picture, inasmuch as the baldness is not as complete as usual. (From 
Ilazen.) 

Tenderness over the mastoid process, with fever, deep seated pain, 
and, if pus has formed, fluctuation, is symptomatic of inflamma- 
tory disease of the mastoid cells. 

The Condition of the Hair. — General falling of the hair fol- 
lows many acute febrile conditions, notably typhoid fever. General 
loss of hair also occurs in gout and myxedema. 

Circumscribed falling of the hair, producing local areas of bald- 
ness, results from tinea tonsurans, scarring from local trauma, and 
neuralgia of the trigeminal nerve, and syphilis. 



382 



PHYSICAL DIAGNOSIS 



In a child baldness in the occipital region, with excessive sweat- 
ing of the head suggests rickets. 

Color of the Hair. — The color of the hair may be altered by local 
application of chemicals, or as a result of metallic poisoning. Thus, 
hydrogen dioxide bleaches the hair, while the hair assumes a green 
color in chronic copper poisoning. 

Canities, whiteness of the hair, a physiologic change in persons 
past middle age, is observed in connection with syphilitic endo- 
arteritis involving the scalp and accompanying trophic nervous dis- 
turbances. 




Fig. 245. — Alopecia areata. A patch that is not as yet completely denuded. (From Hazen.) 

Position of the Head. — Retraction of the head occurs in tetanus, 
strychnine poisoning, meningitis. In children retraction of the 
head may occur during attacks of acute indigestion, the significance 
of which is slight ; but it should not be mistaken for retraction in 
connection with grave affections. 

Lateral deviation of the head is observed in connection with 
wry-neck, due to spasm of the sterno-mastoid muscle, in rheu- 
matic torticollis, in which there is painful contraction of the sterno- 
mastoid and trapezius, in hematoma of the sterno-mastoid, which is 
attended by an oval tumor in the belly of the muscle. In young 



EXAMINATION OF THE HEAD 



383 



children lateral deviation of the head may be due to injury to the 
muscles of the neck during parturition. 

Abnormal fixation of the head is observed in connection with 
retro-pharyngeal abscess, cervical adenitis, rheumatism, arthritis 
deformans, extensive scars from burns, and in Pott's disease. 

Movements of the Head. — Nodding spasm, a rhythmical up 
and down movement of the head, is observed in patients suffering 
with hysteria, and occasionally in connection with rickets. The 
movement may be continuous ; or may be absent during quiescence 
and only brought out by excitement. 

Arrhythmic, purposeless movements of the head occur in Syden- 
ham's Chorea. 




Fig. 246. — Syphilitic alopecia. (From Hazen.) 



Spasmodic movements of tltc head, in which the head deviates 
laterally, occur in spasmodic torticollis. 

Liability to move the head occurs in connection with the flaccid 
paral} T sis of acute anterior polio-myelitis, in caries of the cervical 
vertebrae, and in the late stages of cerebro-spinal meningitis, and 
during comatose states from any cause. 

The Ear. — Congenital Defects. — Among the congenital defects 
of the auricle may be mentioned entire absence of this portion of 
the auditory apparatus; excessive development or defective de- 
velopment of the auricle, macrotia and microtia respectively; the 



384 PHYSICAL DIAGNOSIS 

presence of more than one auricle, or polyotia; malformation or 
absence of the lobule, helix, or antihelix. 

Fistula auris congenita, a rare defect, consists of a short blind 
canal, lined with epithelium, with its orifice either in front of 
or below the tragus. 

Hematoma auris, or othematoma, is a bluish-red swelling involv- 
ing the concha and fossa of the antihelix and helix, the lobule es- 
caping. It is a tropho-neurosis, and the condition is observed most 
commonly among insane patients, in whom it was formerly at- 
tributed to ill-treatment. A similar bluish discoloration, involving 
the entire auricle may follow trauma, due to effusion of blood be- 
neath the peri-chondrium. 

Tophi, small, hard nodules of sodium urate, are frequently 
found in the helix in gouty patients. 

Cysts of the auricle, small, non-inflammatory tumors, contain- 
ing clear fluid, are sometimes encountered about the auricle. They 
are differentiated from peri-chondritis by the absence of pain and 
other inflammatory signs. 

Sebaceous cysts, due to blocking of the ducts of the sebaceous 
glands and accumulation of the secretion, produce roundish tumors 
situated usually in the skin behind the lobule or in the lobule. 

Blueness of the auricle occurs as a sign of cyanosis, also in the 
early stages of frost-bite, in which it becomes later yellowish- 
white. 

Keloid may be encountered on the lobule, due to piercing the 
lobule for earrings, most commonly in the negro race. 

Otomycosis. — In otomycosis, due to the growth of the Asper- 
gillus Niger in the external auditory canal, the canal is studded 
with black spots, which under the microscope reveal the presence 
of the fungus. 

Discharge of blood from the external auditory meatus is in- 
dicative of fracture of the base of the skull or otitis media. In 
the case of fracture of the base of the skull the blood is mixed with 
cerebro-spinal fluid, which prevents coagulation; while in otitis 
media there is admixture with pus. Discharge of pus unmixed 
with blood indicates purulent otitis media or abscess. 



CHAPTER XX V 1 1 

EXAMINATION OF THE FACE 

CONTOUR OF THE FACE 

The contour of the face is altered by many diseases, chief 
among which may be mentioned acromegaly, hydrocephalus, os- 
teitis deformans, leontiasis ossium, leprosy, and facial hemi- 
atrophy and hemi-hypertrophy. 

Acromegaly. — In acromegaly the face assumes an oval or el- 
liptical shape, due to the enlargement of the frontal and malar 
bones, and the mandible, which become massive. Owing to this 
growth the teeth are separated by intervals, the lower teeth 
projecting beyong those of the upper jaw. The ears are lame, 
the nose thickened, and the superciliary ridges are prominent. 
The tongue is large, sometimes protruding from the mouth. The 
eyes are unchanged: and. by contrast with the massive features, 
appeal- abnormally small. 

Cretinism. — In cretinism the face is broad and flat, presenting 
a bloated appearance. The eyes are wide apart, the eyelids are 
thickened, the nose is broad, and negroid. There is pouting of 
the lips and protruding tongue, the child presenting a picture of 
imbecility. 

Myxedema. — In myxedema the lines of expression in the face 
are obliterated by swelling in the subcutaneous tissue. The con- 
tour of the face has been likened to a "full moon." The nos- 
trils and lips are large and thick, the mouth is enlarged, and 
there is usually a reddish patch over the cheek. Other signs of 
myxedema are the dry rough skin, the increase in bulk of the 
whole body, the inelastic swelling of the subcutaneous tissue, 
which does not pit upon pressure, and local deposits of subcu- 
taneous tissue in the supra-clavicular fossae. 

Hydrocephalus. — The face in this disease is triangular with the 
base of the triangle above. The features, which are of normal 
size, present a marked contrast with the enormous forehead. 

Osteitis Deformans. — The face in this disease is triangular 

385 



386 



PHYSICAL DIAGNOSIS 




%4 



J*— 



Fig. 247. — Face of acromegaly. (Butler, after Worchester.) 




Fig. 248. — A case of congenital myxedema. (Woolley, after Kassowitz.) 



EXAMINATION OF THE FACE 



387 




Fig. 249. — Face of myxedema. (P.utler, after Gordinier.) 




Fig. 250. — Leprosy. (From McFarland.) 



388 



PHYSICAL DIAGNOSIS 



with the base directed upward, owing to the thickening of the 
bones of the carnium. The head is carried in a position of for- 
ward inclination. The disease is associated with bowing of the 
bones of the upper and lower extremities, kyphosis, and not in- 
frequently anchylosis of the spine. 

Leontiasis Ossium. — This disease is characterized by progres- 
sive enlargement of the bones of the cranium and face, beginning 
usually in the superior maxillary bones. Blindness occasionally 
develops from pressure upon the optic nerves. 




Fig. 251. — Facial hemi-atrophy. (From Butler.) 



Leprosy.— When the nodes of leprosy develop in the face they 
produce thickening of the skin of the forehead and cheeks. The 
nose is flat and thick; the lips are thick; the ears are thick and 
large, while the eyebrows, eyelashes, and beard are shed, con- 
stituting the Facies Leontina. 

Facial Hemi-atrophy. — In facial hemi-atrophy one-half of the 
face is smaller than the opposite half, with a sharply defined ver- 
tical line of junction. The condition usually begins during child- 
hood in one or two spots on one side of the face. The skin be- 
gins to undergo atrophic changes, followed by a similar involve- 
ment of the underlying subcutaneous tissue, muscles and bones. 



EXAMINATION OP THE PACE 

The skin of the affected half of the face becomes wrinkled, the 
teeth become loose, the eyebrows fall out. The secretion of the 
sebaceous glands is diminished or abolished. The face is drawn 
toward the sound side, rendering the contrast between the two 
sides striking. 

A similar facial asymmetry is encountered in children as a de- 
velopmental defect, often in association with congenital tor- 
ticollis. 

Facial hemi-hypertrophy, the opposite condition, in which one 
side of the face is enlarged, occurs as an anomaly in the develop- 
ment of the face, sometimes associated with hemi-hypertrophy of 
the entire half of the body. 

THE COLOR OF THE FACE 

Pallor of the face occurs in anemia, ischemia, the edema of 
Bright's Disease, and transiently as the result of sudden fright. 

Flushing" of the face may be transient and due to vasomotor 
disturbance, or may be persistent, notably in the early stage of 
acute fevers, as yellow fever. The Hushed cheek of pneumonia 
and the bi-lateral flushing of tuberculosis have been described. A 
flushed face accompanies excessive cardiac hypertrophy, and in 
one form of essential anemia, namely, Chlorosis Rubra, is a 
marked feature of the disease. In apoplectic attacks and in the 
early stages of alcoholic intoxication the face is flushed. 

Cyanosis, or bluish discoloration, particularly noticeable in the 
lips and ears, occurs in uncompensated heart disease. A similar 
bluish discoloration of the face is symptomatic of poisoning with 
coal tar products. 

Yellowish discoloration of the entire face is suggestive of the 
cachexia of malignant disease, syphilis, or chronic malaria. A 
similar hue accompanies chronic constipation with inactive liver, 
certain cases of exophthalmic goiter and Addison's disease. A 
lemon yellow color of the face and body, with maintenance of the 
subcutaneous fat of the body, occurs with pernicious anemia. 

Bluish discoloration, or argyria, occurs in cases of chronic sil- 
ver poisoning. 

Brownish, muddy patches upon the face, termed chloasma, fre- 
quently develops in pregnant women and in women with uterine 
or ovarian disease. 



390 PHYSICAL DIAGNOSIS 



SPASM OF THE FACE 



Spasm of the facial muscles occurs as a result of functional or 
organic disorders. It may be tonic or clonic, uni-lateral, or bi- 
lateral. It is more frequently encountered in women than in 
men. Among the conditions in which facial spasm possesses diag- 
nostic significance may be mentioned: 

Habit Spasm. — This spasm occurs in neurotic children, 
particularly in young girls. It is intensified by excitement or 
examination. It may consist in the rapid winking of an eye or 
the drawing up of one corner of the mouth. The neck muscles 
are frequently involved, the head being given a quick shake at 
the time of the winking. 

Convulsive Tic. — This is a very sudden spasm of the facial 
muscles, frequently involving the brachial muscles as well. The 
spasmodic movements may be almost constant or may occur in 
paroxysms. In extreme cases the spasm may involve all the 
muscles of the body, the movements being very irregular and 
violent. The spasm is often accompanied by explosive utterances, 
echolalia and coprolalia. 

Blepharospasm. — This is a sudden tonic contraction of the 
orbicularis palpebrarum muscle, causing partial or complete 
closure of the eye. More commonly the spasm affects the lateral 
facial muscles also, producing constant twitching of the side of 
the face. Usually uni-lateral, blepharospasm may be bi-lateral. 
The spasm is increased by emotional excitement and voluntary 
movement of the muscles of the face. If not reflex from irrita- 
tion, of the conjunctiva or cornea by a foreign body, it indicates 
involvement of the facial nerve. 

Chorea. — Chorea produces arrhythmical jerking contractions 
of the facial muscles. It is accompanied by the other symptoms 
of the disease, as purposeless movements of the hands and feet. 

Exophthalmic Goiter. — Spasm of the levator palpebral super- 
iors muscle, causing rapid movements of the upper lids occurs 
occasionally in exophthalmic goiter, in which it constitutes Aba- 
die's sign of this disease. 

Tetanus. — Tetanus or lockjaw produces tonic spasm of the 
facial muscles, with the risus sardonicus, or sardonic smile which 
is characteristic of the disease. 



EXAMINATION OP THE FACE 391 

Uni-lateral clonic spasm of one or more facial muscles points 
to irritation of the facial region of the cortex of the brain or to 
irritation of the facial nerve trunk in its course or at its exit by 
tumor or aneurism of the vertebral arterj'. 

THE FOREHEAD 

The forehead should be examined for scars, skin eruptions, and 
nodular swellings. 

Scars upon the forehead may be indicative of former trauma- 
tism or of the eruption of syphilis. 

Eruptions. — The forehead is subject to many cutaneous erup- 
tions, notablythose of measles, smallpox, and syphilis, in which 
last named disease it constitutes the so-called corona veneris. 

Nodular swellings of the forehead may be indicative of gland- 
ers, trichinosis, syphilitic periostitis, or tumor of the cranial 
bones. 

THE EYES 

The Eyelid 

Edema. — Edema of the lids with pumness, occurs in connec- 
tion with the edema of nephritis and in anasarca due to cardiac 
disease or hepatic cirrhosis. Edema of the lids is also noticed 
during the active stage of pertussis, severe coryza, erysipelas, 
cerebral thrombosis, and in arsenic and iodine poisoning. Slight 
puffiness and edema of the lids upon arising in the morning is 
noted in certain persons as a normal phenomenon. 

Duskiness of the lids and the infra-orbital region is symptomatic 
of uterine and ovarian disease, pregnancy, anemia and exhausting 
disease, the molimina of menstruation, and it is said masturba- 
tion. 

Xanthoma is a small, slightly elevated, flattened lipomatous 
new-growth which is occasionally encountered on the eyelids of 
diabetic patients. 

Ptosis. — Ptosis of the upper lid is usually due to syphilitic 
paralysis of the oculo-motor nerve. Usually uni-lateral, ptosis 
may be bi-lateral. A bi-lateral ptosis of brief duration sometimes 
is seen in anemic and overworked women. Ptosis of the lid oc- 
curs with acute encephalitis and as a congenital" condition. 



392 PHYSICAL DIAGNOSIS 

Hordeolum. — A hordeolum or stye is a small abscess in the lid 
margin, situated at the root of an eyelash upon the anterior mar- 
gin of the lid. Styes are acute, run a short course, but are prone 
to recur repeatedly. 

Blepharitis Marginalis. — Blepharitis marginalis, inflammation 
of the lid margin is characterized by the formation of a series of 
scales or crusts along the lid margin, which upon removal ex- 
pose a red, glazed surface. As the scales adhere to the lashes, 
they are sometimes mistaken for the eggs of pediculi. 

Chalazion. — A chalazion or meibomian cyst is a small hard 
tumor of the upper eyelid, imbedded in the tarsal plate. It re- 
sults from obstruction of a meibomian gland, and is prone to be- 
come inflamed and suppurate, 

Epithelioma. — Epithelioma usually is seen upon the lower lid 
in persons past middle life. A history of long duration is usually 
obtainable. 

Chancre. — The initial lesion of syphilis rarely occurs upon the 
lids. 

Lagophthalmos. — Lagophthalmos, imperfect closure of the eye- 
lids occurs with the exophthalmos of Graves' disease, and as a 
result of partial facial nerve paralysis. 

The Conjunctiva 

Pallor. — Pallor of the conjunctiva is a sign of anemia and calls 
for rather than replaces a blood examination. 

Yellowness of the conjunctiva accompanies jaundice, and points 
to hepatic disorder. 

Sub-conjunctival hemorrhage may occur during paroxysms of 
cough in pertussis or asthma, or as the result of local trauma. 

Conjunctivitis. — In inflammation of the conjunctiva the mem- 
brane is red and bathed with muco-purulent or purulent dis- 
charge. Conjunctivitis may result from local infection, or may 
accompany the acute infectious diseases. 

The Globe 

Exophthalmos. — Exophthalmos, or protrusion of the globe of 
the eye, may be indicative of hemorrhage into the orbit, paralysis 
of the ocular muscles, thrombosis of the superior longitudinal 
sinus, tumor of the orbit or superior maxillary bone pushing the 
globe forward, or of exophthalmic goiter. Exophthalmos may be 



EXAMINATION OF THE PACE 393 

uni-lateral or bi-lateral, the latter constituting one of the cardinal 
symptoms of exopthalmic goiter. 

Von Graeffe's sign of exophthalmic goiter consists in the in- 
ability of the upper lid margin to accurately follow the sclero- 
corneal junction downward during downward rotation of the 
globe of the eye. 

Exophthalmos. — Recession of the globe of the eye into the 
orbit, enophthalmos, occurs in exhausting diseases, particularly 
those which are associated with the loss of tissue fluids, as cholera. 
Enophthalmos is also caused by absorption of the orbital adipose 
tissue during chronic wasting disease, notably in tuberculosis, 
diabetes, marasmus, and the cachexia of malignant disease. 

Position of the Globe. — During epileptic seizures and hysterical 
coma the globes of the eyes rotate and turn upward. In hydro- 
cephalus the globe looks downward, while following cranial in- 
juries both globes look toward the side of the injury (conjugate 
deviation). 

Oculocardiac Reflex. — Gentle pressure upon the eyeball of a 
normal subject produces a perceptible slowing of the pulse through 
vagus inhibition. This is a true reflex, the afferent impulse incited 
by pressure upon the globe of the eye being transmitted through 
the ophthalmic division of the trigeminal nerve to the Gasserian 
ganglion and thence through the larger root of the fifth cranial 
nerve to its root of origin. Thence the impulse is transmitted 
downward to the nucleus of origin of the vagus nerve, resulting 
in tonic efferent impulses from this center causing inhibition of the 
cardiac rate. 

Abolition of this reflex indicates a break in the reflex arc at 
some point. Such abolition is noted in cerebrospinal syphilis 
and paresis. Abolition of this retiex is one of the earliest signs 
of syphilitic involvement of the central nervous system, and it 
is a sign which is readily elicited by the general practitioner. 
(E. Murray Auer: Jour. Am. Med. Assn., Mar. 24, 1917.) 

Cornea and Sclera 

Arcus Senilis. — The arcus senilis is a grayish line at the sclero- 
corneal junction which partially encircles the cornea. Present 
in many elderly persons the arcus senilis is particularly frequent 
in arterio-sclerosis and chronic nephritis. 

Interstitial Keratitis. — Inflammation of the interstitial tissue 
of the cornea, leading to partial opacity of this structure or to 



394 PHYSICAL DIAGNOSIS 

small pinkish "Salmon Patches" is nearly always a sign of 
hereditary syphilis. The condition is usually bi-lateral, affect- 
ing children between 5 and 15 years of age, girls being more 
frequently attacked than boys. 

Ulceration. — Comparatively large ulcers of the cornea are ap- 
parent as losses of the surface epithelium; while minute ulcers 
may require the instillation into the eye of a few drops of Fluores- 
cin, which stains the ulcer a bright yellow-green. Corneal ul- 
ceration frequently develops during the exposure of the cornea 
as a result of the exophthalmos of Craves ' disease ; and in cases 
in which the cornea is insensitive owing to disease of the oph- 
thalmic division of the fifth cranial nerve. Corneal ulcer is prone 
to develop during prolonged fevers when the patient lies long 
with the eyes only partially closed. 

Opacity. — Corneal opacity may result from the repair of a 
corneal ulcer, from interstitial keratitis, or as a result of Pannus. 
Corneal opacity sometimes develops during the course of scrofula 
or chronic malaria. 

Staphyloma. — Staphyloma, a bulging of the cornea, usually is 
a sequence of weakening of the cornea by deep ulceration, par- 
ticularly in connection with gonorrheal ophthalmia. 

Yellow Sclerotics. — Yellow discoloration of the sclerotics occur 
in jaundice from hepatic disorder. Small, circumscribed, yel- 
lowish patches, Pinguecula, are innocent growths springing from 
the ocular conjunctiva. 

Bluish Sclerotics occur in connection with chlorosis, in which 
they contrast markedly with the greenish discoloration of the 
skin; also in nephritis, and Addison's disease. 

Scleritis. — In inflammation- of the sclerotic coat of the eye small 
bluish or purplish elevations are left upon the sclerotics. 

THE NOSE 

Shape. — The shape of the nose is altered by a growing tumor 
within the nasal cavities, or from the adjacent bones of the face. 
In cretinism and myxedema the nose is flattened and negroid. 
In syphilis in certain instances the nasal bridge is destroyed 
with the production of a characteristic deformity, the saddle 
nose. 

Redness. — Redness of the nose, aside from being commonly 
associated with a history of chronic alcoholism, is observed in 



EXAMINATION OF THE FACE 



395 



lupus erythematosus, in circulatory disturbances, chronic di- 
gestive disorders, and in amenorrhea. 

Epistaxis. — Discharge of blood from the nose is frequently a 
sign of incipient typhoid fever. A discharge of blood mixed with 
cerebro-spinal fluid occurs with fracture of the base of the skull. 
Discharge of blood from the nose may signify foreign bodies 
in the nose, acute catarrh, local hyperemia from cardiac dis- 
ease, local ulceration which may be simple, carcinomatous, or 
syphilitic, or hemorrhagic diseases as hemophilia, scurvy, or 
purpura hemorrhagica. 




252. — Saddle-nose. (From Eisendrath.) 



Pseudo-Membrane. — A pseudo-membrane develops in the nose 
in nasal diphtheria, a condition which is associated with con- 
siderable swelling of the associated lymph glands. The pseudo- 
membrane may spread to the skin of the face, the conjunctiva 
or the antrum of Highmore. 

Adenoid Vegetations. — In the presence of adenoid vegetations 
in the naso-pharynx the nose is but poorly developed, the nos- 
trils appearing small and pinched. 

Ulceration. — A chronic ulcer on the ala of the nose may be 
tuberculous, carcinomatous or syphilitic. 



396 



PHYSICAL DIAGNOSIS 



THE LIPS 

Pallor of the lips suggests but does not prove the presence 
of anemia. 

Cyanosis, or blueness of the lips, if not due to the ingestion of 




Fig. 253. — Mucous patches. (From Hazen.) 




Fig. 254. — Chancre of the lip of one month's duration. (From Hazen.) 



large doses of coal-tar products, is indicative of regurgitant heart 
disease or pulmonary disease of an obstructive nature as em- 
physema and pneumonia. 



EXAMINATION OF THE FACE 



397 



Parted lips, when dry and cyanotic indicate the dyspnea of 
cardiac or pulmonary disease. Parted Lips in a child with a 
small, pinched nose is suggestive of adenoid vegetations in the 
naso-pharynx. 

Loose, pendulous lower lip accompanies chronic bulbar palsy, 
and less frequently is seen with diphtheritic palsy. 

Herpes of the lips, herpes labialis, occurs with pneumonia 
most frequently, less frequently with malaria, and typhoid fever, 
and other febrile affections. 

Enlargement of the lips accompanies angio-neurotic edema, 




Fig. 255. — Prickle-celled carcinoma of the lower lip in a young man. 
after treating a clinically benign lesion' with caustic pastes. (Gilchrist' 
( From llazcn.) 



khich 
collection. ) 



local abscess formation, and phlegmonous inflammation, and 
obstruction of the lymphatics draining the lips, macroheilia. 

Rhagades, or fissures of the lips, usually affect the lower lip 
near its center, in cold dry weather. Similar fissures develop- 
ing upon the lips near the angle of the mouth in a child are good 
signs of hereditary syphilis. 

Mucous Patch.— Flat, whitish sores near the angles of the 
lips with sharply defined borders, are mucous patehes of 
syphilis. 

Chancre. — An indurated sore on the lip, particularly when de- 



398 



PHYSICAL DIAGNOSIS 



vol oping in a young person, and associated with enlargement of 
the associated lymph glands suggests the initial lesion of 
syphilis. 




Fig. 256. — Double harelip and cleft palate. (From Eisendrath.) 



■■ 



Jg. "»** 




' ■:~TKA i . 



Fig. 257. — Case of complete double cleft in which at birth a tooth hung from the latei 
margin of the alveolar cleft by a thin pedicle of soft tissue. (From Blair.) 



Epithelioma. — A chronic irregular ulcer at the muco-cutaneous 
junction of the lower lip in a person past middle life with en- 
largement of the lymph glands at the angle of the jaw, is sug- 
gestive of epithelioma. 



EXAMINATION OF THE FACE 



399 




Fig. 258.- — Complete double clefl <>f the lip. This is lure accompanied by a double cleft 
of the palate. The intermaxillary bone carries three incisors. I From I'.lair.) 









w 




.'-•'3. .^S 


Wr J 

Rf 1 


a***** 




H 


J .Jg 




■» 


it *■! 






w •< 


B 



Fig. 259. — Noma. A piece has been removed from the left cheek for examination. 
(From the Hunterian Museum, London.) (From Blair.) 



400 



PHYSICAL DIAGNOSIS 



Hare-lip is recognized as a vertical slit or cleft in the upper 
lip on one or both sides of the median line, The cleft may be 
small and confined to the lip, or may be associated with cleft- 
palate, club-foot or other deformity. 

Noma, or cancrum oris, is recognized as a gangrenous mass of 
tissue involving the lip and adjacent surface of the cheek ac- 
companied by a very foul odor. Occurring after measles and 
diphtheria, it is frequently a sequence of ulcerative stomatitis. 

THE BREATH 

Foul Breath.— A foul breath may be caused by carious teeth, 
diseased gums in pyorrhea alveolaris or mercurial poisoning, 
follicular tonsillitis, ulcerative or gangrenous stomatitis, or gan- 
grene of the lung. 

Uremic Breath. — In uremia the breath has a urinous or ammo- 
niacal odor. 

Diabetes.— Diabetes mellitus imparts a sweetish, fruity odor to 
the breath, the acetone breath. 



THE TEETH 

Premature and delayed dentition possesses diagnostic signifi- 
cance. The former suggests hereditary syphilis, while the latter 
accompanies rickets, cretinism, and disorders of nutrition. 




Fig. 260. — Hutchinson's teeth. (Courtesy of Drs. Fordyce and MacKee.) (From Sutton.) 

Early Decay. — In children early decay of the teeth occurs in 
association with rickets and gastro-intestinal digestive disorders. 
In adults carious teeth occur in pregnancy and diabetes mellitus 
as well as in chronic phosphorus poisoning. 

Loosening' of the teeth, with spongy bleeding gums, occurs in 



EXAMINATION OF THE PACE 401 

scurvy and mercurial poisoning. In pyorrhea alveolaris the 
teeth are loosened. 

Hutchinson Teeth. — In hereditary syphilis the upper central 
incisors may present each a notch in its free border. These teeth 
are small and separated by distinct intervals. It affects the per- 
manent and not the deciduous teeth. 

Grinding* of the teeth during sleep in children is observed in 
connection witjh rickets and derangements of digestion. 

THE GUMS 

Blue Line. — A blue line on the margin of the gum is indicative 
of chronic lead poisoning. In the early stages of the intoxication 
the line is not continuous, but occurs as a scries of blue dots at the 
base of the teeth. The line may extend along the entire length 
of the gum, or may be limited to the bases of a few of the front 
teeth in either jaw. 

In chronic copper poisoning a blue or greenish line develops 
along the roots of the teeth. 

Red Line. — A red line along the gingivo-dental margin occurs 
with pyorrhea alveolaris, gingivitis, frequently in diabetes, and 
it is said in tuberculosis. 

Spongy Gums. — In ulcerative stomatitis the gums are swollen, 
spongy, of deep red or purple color, with a line of ulceration ad- 
jacent to the incisors, sometimes extending to all the teeth. 

In scorbutus the gums are spongy, bleed easily, and the teeth 
are loosened. In mercurial poisoning the gums are spongy, there 
is excessive salivation, and fetid breath. 

In pellagra the gums are spongy, and assume a cerise color. 

Epulis. — An epulis is a small, soft tumor springing from the 
gums or alveolar process of the superior maxillary bone. It is 
usually a giant-cell sarcoma. 

THE TONGUE 

Size of the Tongue. — Hypertrophy of the tongue occurs in in- 
fants as a congenital condition, the tongue reaching Such enor- 
mous size that it cannot be contained in the mouth. Acquired hy- 
pertrophy of the tongue is seen in acromegaly, myxedema, and cre- 
tinism, in acute glossitis, and as a result of lymphatic obstruction, 
macroglossia. 

Atrophy of the tongue occurs as a part of glosso-labio-laryngeal 



402 PHYSICAL DIAGNOSIS 

palsy. Uni-lateral atrophy of the tongue may accompany facial 
hemi-atrophy and as a result of hemorrhage or tumor developing 
in close proximity to the hypo-glossal nucleus. 

Movements of the Tongue. — The manner in which the tongue 
is protruded upon request as well as the integrity of its move- 
ments during mastication and speech should be carefully noted. 
Thus in nervous and neurasthenic subjects the tongue is pro- 
truded quickly upon request, whereas in typhoid states the pro- 
trusion is very slow and tardy. 

In uni-lateral paralysis of the tongue, accompanying hemiplegia 
or uni-lateral hypo-glossal palsy the tongue deviates from the 
median line when protruded. In bi-lateral paralysis of the tongue, 
as a result of bulbar paralysis, or symmetrical lesions of the cor- 
tex or supra-nuclear tracts, the tongue lies upon the floor of the 
mouth and cannot be protruded. 

Inability to perform the finer movements of the tongue con- 
cerned in mastication and speech is an early sign of glosso-labio- 
laryngeal paralysis, or true bulbar palsy. A similar impairment 
of the movements of the tongue accompanies pseudo-bulbar paral- 
ysis, a state in which the central lesion is not situated in the 
medulla, but in the lingual fibers from the cortex above the me- 
dulla. This condition of pseudo-bulbar palsy is not accompanied 
by atrophy of the tongue, which only occurs in true bulbar palsy, 
or glosso-labio-laryngeal paralysis. The absence of lingual 
atrophy in the former indicates that the causative lesion is in the 
upper neurone, above the nucleus. 

Tremor. — A coarse or fine tremor of the tongue upon protrusion 
accompanies many organic nervous diseases and typhoid states, 
and exhausting fevers. In organic nervous involvement the tre- 
mor is constant, whereas in typhoid states it only develops upon 
protrusion of the tongue. 

Spasm. — Tonic spasm of the tongue accompanies Thompson's 
disease, or myotonia congenita. A similar tonic spasm of the 
tongue occurs from reflex irritation of the trigeminal nerve. 
Clonic spasm of the tongue is noted in connection with chorea, 
epilepsy, puerperal melancholia, multiple sclerosis and paresis. 

Ulceration. — Ulceration of the dorsum of the tongue may be in- 
dicative of simple ulceration, tuberculosis, syphilis, or carcinoma. 

Simple ulceration results from local trauma or irritation. Not 
infrequently in young children an ulcer of the frenum is noted, 
resulting from the irritation of the sharp edges of the lower 
central incisor teeth. 



EXAMINATION OF THE FACE 



403 



A tuberculous ulcer of the tongue may be oval, linear, or stellate. 
The surface of the ulcer is pale and uneven, covered with grayish 
exudate, presenting no evidences of acute inflammation. It is usu- 
ally accompanied by tuberculosis of the cervical lymphatic glands. 





Fig. 261. — Illustrating tuberculous lesions of the tongue, A and B in the same indi- 
vidual, healing after two and one-half years' treatment; C. on the dorsum of the tongue 
of an individual suffering from active advanced tuberculosis; no signs of healing shown, 
patient dying of the disease a few months later. (From Pottenger.) 



A syphilitic ulcer of the tongue produces a chronic dissecting 
glossitis characterized by multiple fissures situated principally 
upon the lingual edges, but crossing the dorsum of the tongue in 
various directions. The cervical lymph glands are commonly 
enlarged. 



404 



PHYSICAL DIAGNOSIS 



A carcinomatous ulcer of the tongue is solitary, with induration 
of the surrounding tissues, somewhat simulating a chancre; but 
the ulcer does not disappear under anti-syphilitic therapy. The 
carcinomatous ulcer is apt to develop in elderly persons, and the 
accompanying glandular enlargement appears more tardily than 
in the other lingual ulcers. 

Geographical Tongue. — In the geographical tongue there are 
one or more patches upon the dorsum in which the surface 
epithelium has desquamated, the patches extending at the periph- 
ery while healing at the center, pursuing a circinate course 




Fig. 262.— "Cobblestone tongue" due to gumrnous deposits two years after infection. 

(From Hazen.) 



over the dorsum, two or more patches frequently coalescing. Oc- 
curring in under-nourished children and adults, the geographical 
tongue possesses little significance. 

Leukoplakia. — In leukoplakia irregularly shaped plaques of 
thickened epithelium appear upon the dorsum of the tongue. The 
plaques are smooth, pale, slightly elevated above the surrounding 
surface of the tongue, one to two centimeters in diameter, and 
non-ulcerative. Their recognition is important in that they have 
become the starting point of carcinoma of the tongue. 

Smoker's Patch. — In persons who use tobacco to excess a round 
or oval patch is sometimes encountered upon the dorsum of the 



EXAMINATION OF THE FACE 405 

tongue near the tip, slightly elevated, red or pearly in color, 
smooth, and with no tendency to ulceration. 

Cysts. — Mucous and blood eysts occasionally develop in the 
tongue. Rarely the cysticercus cellulosae, the larva of the taenia 
solium may produce a cyst upon the under surface of the tongue, 
or an echinococcus cyst may be encountered in this region. Also 
a Ranula, due to obstruction and dilatation of the ducts of 
Blandin-Nuhn's glands may be found on the under surface of the 
tongue near the tip. 

Thrush. — In thrush the dorsum of the tongue is covered or 
studded with small, white flakes, resembling closely deposited 
flakes of coagulated milk, but differing from them in that they 
cannot be wiped off; and, if removed, leaving bleeding points. 

Indentation of the edges of the tongue by the teeth, is noted 
during prolonged fevers when the hygiene of the oral cavity is 
not properly practiced. In pellagra there are similar indenta- 
tions in the deep red border of the tongue occurring with this 
disease. 

Pellagra. — In pellagra the tongue presents a fiery red border 
and tip, showing indentations corresponding to the teeth with 
which it is in contact. Frequently small circumscribed sloughs 
are encountered upon the borders of the tongue, corresponding to 
areas of epithelial denudation. The gums are spongy and of a 
cerise color, while the month is the site of a stomatitis of variable 
intensity. The condition of the tongue and buccal mucosa is in- 
tensely painful. 

Dryness of the TongTie.— The tongue in health is kept mois- 
tened with the salivary secretions and the buccal secretions. 
When this secretion is inhibited during acute fevers, the admin- 
istration of atropine, or from excessive loss of body fluids inci- 
dent to prolonged diarrhea and profuse hemorrhage the tongue 
is abnormally dry, and not infrequently covered with a thick 
brown coat. 

Color. — The ingestion of various chemicals and drugs and cer- 
tain diseases alter the color of the tongue. The tongue is white 
following the ingestion of mercuric chloride, ammonia, sulphuric 
acid and phenol. The ingestion of caustic potash or soda causes 
reddening of the tongue with evidences of destructive action of 
these substances. Hydrochloric and nitric acids color the tongue 
yellow. 

In Addison's disease and purpura hemorrhagica the tongue not 
infrequently exhibits small non-elevated purple spots ; while xan- 



406 PHYSICAL DIAGNOSIS 

thelasma produces yellowish, slightly elevated dots along the 
margins of the tongue. 

In scarlatina the tongue is bright red, the filiform papillae con- 
trasting sharply with the slight white furring of the tongue, the 
strawberry tongue. 

THE BUCCAL CAVITY 

Color. — The buccal mucosa is pallid in anemic states, is exces- 
sively red during local inflammation as in catarrhal stomatitis, 
and is bluish in cyanosis and argyria. 

Moisture. — Excessive moisture of the buccal cavity, incident 
to over-activity of the salivary and buccal glands accompanies 
local inflammation, following the ingestion of massive doses of 
the iodides and mercurial salts, during the early stages of small- 
pox and typhus fever, occasionally during pregnancy, and during 
convalescence from typhoid fever. 

Dryness of the buccal cavity, or xerostomia, owing to temporary 
arrest of the salivary and buccal secretions occurs during acute 
febrile diseases, diabetes mellitus, in mouth breathers and lesions 
of the pons and medulla affecting the integrity of the nervous 
mechanism of the salivary glands. 

Eruptions. — In variola and varicella vesicles may appear upon 
the buccal mucosa, similar vesicular eruption accompanying her- 
pes buccalis and aphthous stomatitis. Measles is accompanied by 
pathognomonic lesions upon the mucosa, Koplik's spots. These 
are minute red spots with a bluish-white center, occurring upon 
the inner surface of the cheek opposite the molar teeth. The' 
number of the spots varies ; there may be only one or two or the 
mucosa may be fairly studded with them. The spots occur early, 
disappearing with the inception of the exanthem. 

Mucous Patch.— The mucous patch of syphilis is frequently en- 
countered upon the buccal mucosa. In all suspicious cases a care- 
ful search of the mucous lining of the cheek should be made for 
these lesions. 

Noma, cancrum oris, or gangrenous stomatitis, develops as an 
indurated spot upon the mucous lining of the cheek near the 
angle of the mouth, later involving the entire thickness of the 
buccal wall, the gangrenous tissue emitting an especially foul 
odor. 



EXAMINATION OF THE FACE 407 

THE PHARYNX 

In examining the pharynx the tongue should be gently de- 
pressed with a wooden spatula or other type of tongue depressor, 
while the patient is instructed to utter the word "AH," which 
lowers the base of the tongue, permitting a good view of the 
posterior pharyngeal wall. 

Redness. — Abnormal redness of the pharyngeal wall accom- 
panies acute inflammation of the pharynx, which may be pri- 
mary, or occur with the acute exanthematous fevers, or acute in- 
fectious disease, as influenza and erysipelas. 

Eruptions. — The eruptions of variola, varicella, and of herpes 
buccalis are often distributed generally over the pharyngeal wall. 

Ulceration of the pharyngeal wall is indicative of tuberculosis, 
syphilis, or typhoid fever. 

Bulging of the posterior pharyngeal wall, either in the median 
line or laterally, occurs in post-pharyngeal abscess, which is often 
due to tuberculous disease of the cervical vertebrae. 

Elongated Uvula.— Elongation of the uvula may occur from 
infammation of the adjacent pharyngeal mucous membrane, but 
it may also be a part of the general edema incident to cardiac or 
renal disease. 

Perforation of the soft palate is usually of syphilitic origin. 

Paralysis of the soft palate may be uni-lateral or bi-lateral. 
Paralysis of the palate is detected by observation of its move- 
ments while the patient speaks, at which time the normal palate 
moves upward. If this normal mobility of the palate is lost on 
one side, the paralysis is uni-lateral ; if both sides remain im- 
mobile, the paralysis is bi-lateral. Bi-lateral palatal paralysis is 
not infrequently attended by regurgitation of fluids through the 
nose upon the attempt to swallow. Paralysis of the palate may 
be part and parcel of glosso-labio-laryngeal paralysis, may de- 
pend upon cervical caries, or may be due to diphtheritic paralysis. 

THE TONSILS 

Inflammation. — A moderate grade of tonsillar inflammation re- 
sulting in painful deglutition, accompanies most of the acute exan- 
thematous fevers. In acute follicular tonsillitis the tonsils are 
moderately enlarged, red, and studded with minute yellowing 
dots, corresponding to plugs of mucus, epithelium and bacteria 
which can be squeezed from the tonsillar crypts. 



408 PHYSICAL DIAGNOSIS 

Chronic simple enlargement of the tonsils, in which the two 
bodies may almost meet in the median line, occurs occasionally 
in childhood. 

Pseudo-membrane. — A pseudo-membrane upon the tonsil, per- 
haps involving the pharyngeal wall as well, if not diphtheria, is 
apt to be due to streptococcic inflammation or scarlatina. 

Ulceration. — Ulceration of the tonsil is due to tuberculosis, 
syphilis, or, if in an elderly person, to carcinoma, or in a younger 
subject to sarcoma. 

Peri-tonsillar Ulceration (Vincent's Angina). — In this disease 
which is a uni-lateral affection, there is ulceration of the peri- 
tonsillar tissues, with a variable amount of yellowish exudate 
covering the tonsil. There is marked swelling of the submaxil- 
lary lymph glands. 



CHAPTER XXVIII 
EXAMINATION OF THE NECK 

Shape. — Certain variations in the shape of the neck character- 
ize certain diseases. Thus, a short, thick neck suggests hyper- 
trophic emphysema, and is a constant accompaniment of the 
barrel chest of this disease. Similarly in plethoric patients the 
neck is short and thick. A long, slender neck, on the other hand, 
is frequently observed in phthisical patients. 

Rigidity. — This may be caused by tuberculous disease of the 
cervical vertebra? or rheumatism of the muscles of the neck. 
Tender, enlarged cervical glands or boils or carbuncles may 
cause the patient to hold the neck rigid. As previously stated, 
retraction and rigidity of the neck occur in meningitis, tetanus, 
and strychnine poisoning. Rigidity of the neck with fixation of 
the head is also observed as a result of arthritis deformans, spas- 
modic torticollis, and due to scars from extensive burns of the 
neck. 

Prominent Sterno-mastoids. — Abnormal prominence of both 
sterno-mastoid muscles is usually a sign of long continued dysp- 
nea, due to pulmonary or cardiac disease. An undue prominence 
of one sterno-mastoid may be caused by spasmodic torticollis, a 
tumor, cyst, or abscess of the muscles. 

Torticollis. — This is a spasm, usually tonic, rarely clonic, of 
the sterno-mastoid and trapezius muscles. Its cause is occasionally 
irritation of the spinal accessory nerve which supplies these mus- 
cles, by cicatrices or enlarged glands. Most cases, however, occur 
without assignable cause. Congenital torticollis is caused In- 
congenital shortness of one sterno-mastoid and is not due to spasm 
in any sense. 

Deflection of Larynx and Trachea. — The larynx and trachea, 
the latter overlaid by the thyroid gland, occupy the median line 
of the neck. Deflection of these structures to one or the other 
side may be due to atrophy of the muscles on one side of the 
neck, to tumor or aneurism in the adjacent tissues, or to disease 
of the thoracic viscera. Of the last named factors, fibroid phthisis 
is very important, the structure being deflected toward the side 
of the cirrhotic lung. 

409 



410 



PHYSICAL DIAGNOSIS 




Fig. 263. — Large cystic goiter. (From Fisendrath.) 




Fig. 264. — Goiter. (From Woolley.) 



EXAMINATION OF THE NECK 



411 



Movements of the Larynx and Trachea. — Marked inspiratory 
descent of the larynx occurs in Laryngeal stenosis. Normally the 
larynx descends slightly during inspiration and rises to a similar 
degree during expiration. When this mobility is abolished in a 
dyspneic patient the cause of the dyspnea is below the larynx 
as, for instance, pressure on a bronchus by enlarged glands or 
aneurism. 

Tracheal Tug. — This is an important sign of aneurism of the 
thoracic aorta, and has been discussed in a previous section. 




Fig. 265. — Palpation of submaxillary and submental glands. (From Kisendrath.) 



Thyroid Gland. — This gland may be increased in size or it 
may be diminished in size. 

Enlargement of the thyroid may involve one or both lobes. 
The degree of enlargement varies. There may be a small local- 
ized swelling at one point, or the entire gland may be found 
greatly enlarged, exerting dangerous pressure upon the trachea, 
carotid arteries, and nerves. The consistence of the enlarged 
gland varies. In the fibrous forms of goiter the gland is hard, 
while in the cystic form it is soft and may fluctuate. Some- 
times a thrill may be detected on palpating the gland, accom- 
panied by a systolic murmur, due to the increased vascularity 



412 



PHYSICAL DIAGNOSIS 



of the gland. An enlarged thyroid gland moves with the trachea 
during deglutition. 

The significance of a thyroid enlargement varies with the 
cause. It may.be due to abscess following an infectious disease, 
or to malignant growth. If due to simple hypertrophy of the 
gland, the tumor will usually appear during pregnancy, and dis- 
appear spontaneously after labor. If fluctuation is detected, it is 
probably a cystic goiter or an abscess of the gland. If the en- 
largement be due to exopththalmic goiter it will be associated 
with the cardinal symptoms of this disease, as tachycardia, 
exophthalmos, and tremor. 

Atrophy of the thyroid gland, revealed by the presence of a 




Fig. 266. — Congenital hemangioma of neck. (From Fisendrath.) 



depression in the normal position of the gland, occurs in cretinism 
and myxedema. 

Enlarged Glands. — Enlarged lymph glands in the cervical re- 
gion may have a varied significance, the significance varying with 
the location of the glands involved and with the state in which 
they are found; namely, whether hard or soft and fluctuating, 
whether single and individual or matted together in a mass. 
Among the causes of glandular enlargement in this region may 
be mentioned the following conditions. 

The lymph glands at the angle of the jaw may enlarge from 
follicular tonsillitis, diphtheria, scarlatina, measles, German 



EXAMINATION OF THE NECK 



413 



measles, varicella and smallpox; also in erysipelas, glanders, 
whooping cough, and retro-pharyngeal abscess. In these condi- 
tions the glands are acutely tender for a period and usually un- 
dergo resolution without abscess formation. 

The sub-maxillary glands, just below the chin may enlarge 
as a result of carious teeth, stomatitis, syphilis, mumps, cancer 
of the lower lip or anterior portion of the tongue. This group of 
glands are often enlarged in cases of actinomycosis. 







•**> ^ 




Fig. 267. — Ilodgkin's disease. 



The parotid lymph glands enlarge in mumps, and diseases of 
the upper pharynx and skin of the face, as well as in malignant 
disease of the parotid gland. 

The occipital glands are enlarged in German measles, often the 
only group attacked in this disease. Enlargement of this group of 
glands is also a valuable sign of syphilis, and occurs also in cases 
of pediculosis of the scalp. 

Tuberculosis of the cervical glands causes glandular enlarge- 
ment, particularly in the glands under the jaw. The glands 
tend to become adherent to the cutaneous structures and often 
suppurate. 



414 



PHYSICAL DIAGNOSIS 



Hodgkin's disease causes glandular enlargement in the lymph 
glands of the neck, of long standing, involving also the glands of 
the axilla, groin, and showing slight splenic enlargement. 

Lymphatic leukemia is a cause of enlargement of the cervical 
lymph glands. 

Enlargement of the lymph glands above the left clavicle points 
to cancer of the stomach. 




Fig. 268. — Cervical glands commonly involved in tuberculosis. (From Fisendrath.) 

The condition of the glands and the duration of the enlarge- 
ment possess diagnostic significance. Thus, acute painful cases 
of short duration are probably due to a tonsillitis, or the exan- 
themata. Chronic cases, of long standing, may be due to tuber- 
culosis, syphilis, or Hodgkin's disease. In tuberculosis the glands 
are matted together with tendency to suppurate. In syphilis 
they are hard and small. In Hodgkin 's disease the glands are en- 
larged, but remain separate, and do not tend to suppurate. 



EXAMINATION OF THE NECK 



415 




Fig. 269. — Bronchial cyst. (From Eisendrath.) 




Fig. 270. — Bronchial cyst. (From McFarland.) 



416 PHYSICAL DIAGNOSIS 

Abscess. — An abscess in the cervical region is almost certainly 
of tuberculous origin, being the result of tuberculosis of the 
cervical lymphatic glands. Also Pott's disease high up in the 
neck may be complicated by abscess (Cabot). 

Scars. — Scars in the neck are usually the result of cervical tu- 
berculosis (Cabot). Traumatism and wounds may of course leave 
scars in this region. 

Branchial Cysts and Fistulae. — Branchial cysts and fistulae, 
resulting from imperfect closure of the embryonic branchial 
clefts, are encountered in rare instances. A branchial cyst is 
formed by closure of the pharyngeal and cutaneous surfaces of 
the cleft without closure of the intervening mesoblastic tissues. 
Branchial fistulae may be complete or incomplete, depending 
upon the degree of fusion of the embryonic clefts, the incomplete 
being represented by diverticula, either external or internal, 
opening into the pharynx. 

Ludwig's angina, a painful indurated swelling beneath the angle 
of the jaw, due to septic infection of the tissues surrounding the 
submaxillary gland, is an occasional cause of dyspnea and dyspha- 
gia which may become alarming. 

Woody or ligneous phlegmon, an insidious induration of the sub- 
cutaneous tissues of the neck, involving the lateral or anterior 
aspect of the cervical region, is occasionally encountered. In 
some instances the structures are indurated from the jaw to the 
clavicle ; the condition is attended by little pain and no fever. 



SECTION II 
EXAMINATION OP THE BAND AND A KM 



CHAPTER XXIX 
THE BAND 

THE NAILS 

Pallor. — Pallor of the nails is a sign of anemia, and it is well to 
bear in mind the rule Laid down by Stephen McKenzie, that when 
pressure upon the tip of the finger completely drives the blood 
from beneath the nail, the red corpuscles arc present in only 

half their normal number. 

Cyanosis. — Cyanosis or blueness of the nails is a sign of de- 
ficient aeration of the blood, either due to a failing heart, an ob- 
structive pulmonary lesion, or the ingestion of coal tar products. 
As has been stated, cyanosis appears very early under the nails 
and about the lips. 

White spots in the nails are usually significant of trophic 
changes in the nail; less commonly they are due to injury of the 
matrix by picking at the base of the nail. 

Capillary Pulse. — The capillary pulse has been described under 
the section upon the examination of the circulatory organs: and 
as stated, is a valuable sign of aortic regurgitation or Corrigan's 
disease. 

Transverse Groove. — A transverse groove on the back of a nail 
is a sign of a recent acute illness. The groove has its incep- 
tion at the base of the nail and its distance from the base 
when observed may indicate when convalescence from the illness 
in question commenced. Thus it requires six months for the 
groove to progress from the base to the free edge of the nail; 
hence, if it be encountered half way between the matrix and the 

417 



418 



PHYSICAL DIAGNOSIS 



free edge, it is an indication that convalescence began approxi- 
mately three months previously. 

Longitudinal ridges in the nails are said to be a reliable sign of 
gouty diathesis. Certainly the ridges are encountered in many 
gouty patients. 




Fig. 271. — Hypertrophy of the nails. (From Hazen.) 




Fig. 272. — Symmetrical atrophy of nails. (Courtesy of Dr. J. C. F. King and Dr. H. G. 
Parker.) (From Sutton.) 



Incurvation of the nails, with or without clubbing of the 
finger-tips is a sign of chronic disease of the heart or pulmonary 
tissues, such as cardiac failure, aneurism, phthisis, or emphysema. 



EXAMINATION OF THE HAND 419 

The incurvation may be lateral or longitudinal, or may occur in 
both directions. 

Hypertrophy of the nails, particularly in the transverse di- 
rection associated with thickening and sometimes with twisting, 
occurs after acute fevers, particularly foil owing typhoid fever, 
in connection with syphilis, and in sclerodactyly. A similar hy- 
pertrophy of the nail may result from eczema, may be encoun- 
tered in a subject with Raynaud's disease, and in pulmonary 
osteo-arthropathy. The nail may be simply hypertrophied with- 
out any defect in its structure (megalonychosis) . or in addition 
to hypertrophy the nail may be twisted spirally I onychogry- 
posis). 

Atrophy of the nails, with ulceration at the base, occurs in Mor- 
van's disease, a syndrome which develops as a sequence of neuritis 
and syringomyelia. Atrophy of the nail may follow psoriasis of 
the fingers. 

Arrested Growth. — The growth of the nails is impaired or 
ceases on the paralyzed side in hemiplegia. A similar arrest of 
growth of the nails of the paralyzed limb occurs in infantile paral- 
ysis. Arrest of growth of a nail may be detected In staining the 
nails at identical points upon the two hands and observing any 
discrepancy between the growth of the nails. 

Excessive brittleness of the nails is noted in persons of gouty 
diathesis, the nails frequently presenting the longitudinal stria- 
tions which have been described. 

Onychia, ulceration of the nail matrix, occurs in children with 
hereditary syphilis, or scrofula, and it is said in persons who are 
addicted to the chloral habit. 

Paronychia, or whitlow, an acute inflammation of the tissues 
surrounding the matrix of the nail, may be a sequence of local 
trauma or may be caused by lateral hypertrophy of the nail. 

Indolent Sore. — An indolent sore near the root of the nail, if 
indurated and associated with enlargement of the epitrochlear 
lymph glands, is usually a chancre: but may be due to tubercu- 
losis. 

THE FINGERS 

Tophi. — Tophi are concretions of sodium biurate which occur in 
the joints of the fingers in gouty subjects. They are more promi- 
nent on the dorsal surface of the joints, and may break through 



420 



PHYSICAL DIAGNOSIS 




Fig. 273. — Heberden's nodes. (From Butler.) 




Fig. 274. — Pulmonary csteo-arthropathy. (From Butler.) 



EXAMINATION OF THE HAND 



421 



the skin, when they constitute the "chalk stones" of the disease. 

Enlarged Joints. — Enlargement of the joints of the fing 
is seen in connection with gout and chronic rheumatism. In 
rheumatism the enlarged joints are often hot and painful. 




Fig. 275. — Arthritis deformans. (From Butler.) 




Fig. 276. — Morvan's disease. (From Butler.) 



Heberden's Nodes.— These nodes, also termed Haygarth s Nodos- 
ities, are knobby enlargements of the proximal ends of the ter- 
minal phalanges. They are noted in gout and in arthritis de- 
formans, in which diseases they are said to be of good prognostic 
significance. 



422 PHYSICAL DIAGNOSIS 

Clubbed Fingers (Hippocratic Fingers). — Clubbing of the 
terminal phalanges accompanies many chronic diseases of the 
heart and lungs, notably chronic bronchitis, emphysema, phthisis, 
and chronic pleurisy, and uncompensated cardiac disease. The 
nails are commonly incurved. An exaggeration of this condition 
with swelling of the carpal joints is noted in pulmonary osteo- 
arthropathy. 

Distortions of the fingers accompany gout, chronic rheumatism, 
and arthritis deformans. The distortions are not produced merely 
by fixation of the fingers in abnormal positions, but are produced 
by organic changes, in gout by the deposition of sodium biurate 
in the joints, in arthritis deformans by absorption of bone and 
the growth of exostoses. The fingers are most frequently de- 
flected toward the ulnar side of the hand. 

Dactylitis. — Dactylitis is usually a sign of hereditary syphilis, 
less frequently of tuberculosis. In the evolution of the deformity 
a fusiform purple swelling, which is prone to undergo ulceration 
with sinus formation, appears upon one or more of the fingers, 
most frequently involving the proximal phalanges. 

Raynaud's Disease. — In Raynaud's disease, or "dead fingers" 
the fingers are bluish-black or livid, gangrene occurring in spots 
and leading in many instances to spontaneous amputation of the 
fingers. 

Morvan's Disease. — In this disease the fingers are the site of 
painless, destructive whitlows, which have their inception ad- 
jacent to the base of the nail, leading to necrosis of the terminal 
phalanges and marked swelling of the fingers. 

SHAPE OF THE HAND 

The shape of the hand varies in different subjects and under 
varying conditions of age and occupation. The broad, heavy 
hand is said to be indicative of a sanguine personality, while the 
slender hand is said to indicate a nervous temperament. Bluish 
dotting of the hand of a coal miner points to the possibility of 
anthracosis, while in old age and in malignant disease and phthisis 
the hand is small and withered. 

Spade Hand. — In acromegaly and myxedema the hand is large, 
with thick fingers and broad nails. In myxedema the hand is 
boggy, but does not pit on pressure ; whereas in acromegaly the 
hand is hard, as the basis of the hypertrophy is osseous. 



EXAMINATION OF THE HAND 



423 




Fig. 277. — Spade hand. (From Butler. 







Fig. 278. — Claw hand. (Maiii-cn-griffe.) (From Eisendrath.) 



424 



PHYSICAL DIAGNOSIS 



Claw-Hand (Main-en-griffe). — In amyotrophic lateral sclerosis 
and progressive muscular atrophy the proximal phalanges are 
drawn backward toward the wrist, while the second and third 
phalanges are flexed toward the palm. The underlying cause 




Fig. 279. — Accoucheur's hand. (From Butler.) 




Fig. 280. — Wrist-drop. (From Eisendrath.) 



of this deformity is a paralysis of the lumbrical and inter-osseous 
muscles, causing the proximal phalanges to assume a state of dor- 
sal extension, while the distal phalanges are flexed. 

Hemiplegic Hand. — In hemiplegia the contractures of the arm 



EXAMINATION OP THE HAND 425 

and hand are replaced in course of time by permanent deformity. 

The fingers in this deformity are flexed upon the palm, the wrist 
is flexed upon the forearm, while the elbow is retained in a state 
of permanent flexion and applied closely to the side of the 
body. 

Seal-Fin Hand. — In chronic gout and rheumatoid arthritis the 
entire hand is deflected toward the ulna as a result of spasm of the 
extensor muscles, imparting to the hand a fancied Resemblance to 
the fin of a seal. 

Ape Hand. — This type of manual deformity is the result of wast- 
ing of the thenar and hypothenar muscles in progressive muscu- 
lar atrophy, causing the hand to assume a position in which the 
fingers and thumb are on one parallel plane. 

Accoucheur's Hand. — In this type of manual deformity, which 
occurs in Tetany, the thumb is flexed into the palm of the band. 
while the fingers, flexed at the metacarpophalangeal joints and 
first inter-phalangeal joints, are extended at the second inter- 
phalangeal articulations and pressed closely upon the thumb. 

Dupuytren's Contracture. — This is a permanent painless flex- 
ure of one finger of one or both bands into the palm. .Most com- 
monly the little finger alone is involved, but sometimes the ring 
finger or other fingers are flexed also. Dupuytren's contracture 
results from burns or other injuries to the palmar fascia. 

Ganglion. — A ganglion is recognized as a localized swelling 
upon the dorsum of the hand. It is presumably caused by cystic 
degeneration of a synovial fringe within a tendon sheath. Gan- 
glia are not infrequently tuberculous in origin. 

Wrist-Drop. — In wrist-drop the band bangs powerless from the 
wrist. It is significant of neuritis or paralysis of the musculo- 
spiral nerve. 

TREMOR OF THE HAND 

Intention Tremor. — Intention tremor is a tremor of the band 
which is converted into coarse shaking movements Avben the 
patient endeavors to perform any act, such as bringing a glass 
of water to the lips, or holding a pen to write. Intention tremor 
is a cardinal sign of multiple sclerosis and is sometimes noted in 
hysteria. 

Paralysis Agitans.— In paralysis agitans the patient is sub- 
ject to a constant tremor of the hands, in which the thumb and 
index finger are held in close proximity to one another or in actual 



426 



PHYSICAL DIAGNOSIS 



contact, describing a rolling movement as if they were rolling a 
pill (Pill-rolling tremor). The tremor in marked contrast to that 
of multiple sclerosis disappears completely during voluntary 
movements of the hands. 

Professional Spasm. — Writers, violin players, and others who 
constantly employ one set of muscles are often troubled with 
painful spasms in the muscles used, incapacitating them for their 
usual occupations. 




Fig. 281. — Pellagra. 



Athetosis. — This term refers to certain slow and purposeless 
movements of the fingers which are encountered in patients suf- 
fering with organic disease of the central nervous system. 

Pellagra. — The cutaneous manifestations of pellagra involve the 
extensor aspect of the hand and forearm, producing an eruption 
of an erythemato-squamous type. In incipient cases, in the stage 
of initial erythema, the eruption resembles closely ordinary sun- 



EXAMINATION OF THE HANI) 



427 



hu in or solar erythema. In the latter evolution of the disease the 
superficial epithelium takes on a brown pigmentation, and 
desquamates in scales. Sensation is lost in the areas of des- 




Fig. 282. — Pellagra in child less than 3 years old. 



quamation. The skin covering the elbows should always be in- 
spected for the eruption. The eruption may involve the dorsum 
of the foot or the face, and rarelv the neck or chest. 



CHAPTER XXX 
• THE FOREARM AND ARM 
EXAMINATION OF THE FOREARM 

Epiphyseal enlargement of the forearm bones at the wrist is 
indicative of rickets. It is usually accompanied by the rachitic 
rosary and other signs of the disease. 

Enlargement of the lower end of the radius with clubbing of 
the fingers occurs in pulmonary osteo-arthropathy the result of 
chronic pulmonary or cardiac disease. 

Enlargements or nodes along the shafts of the radius or ulna 
are usually due to syphilitic periostitis. 

Erythema nodosum occasionally occurs upon the forearm, 
manifesting itself by the appearance of elevated, red, shining 
nodular swellings, which are very painful upon pressure. 

Edema of the forearm, usually affecting the arm as well, results 
from thrombosis of the axillary vein, or from the pressure of me- 
diastinal tumors upon the subclavian vein. 

EXAMINATION OF THE ARM 

Tumors. — A superficial tumor arising in the arm is most apt 
to be lipomatous. It is often lobulated. A ruptured biceps pro- 
duces a sharp tumor over the lower portion of the arm. A deeply 
seated tumor of the arm is most likely to prove sarcoma of the 
humerus. An acute painful swelling of the humerus following 
typhoid fever or scarlatina is due to acute periostitis. 

Small Nodular elevations upon the humerus are usually the re- 
sult of syphilitic periostitis. 

Paralysis. — Paralysis of one arm may be total, the arm hang- 
ing limply, without power of movement, or may be partial. Par- 
tial brachial paralysis may assume one of two types; namely, the 
upper arm type of Duchenne-Erb, or the lower arm type of 
Klumpke. Brachial paralysis may be the result of trauma at 

428 



EXAMINATION OF THE ARM 



429 



birth, or may resull from compression of the brachial plexus by 
a tumor or by a crutch. Some cases arc duo to a faulty position 
of the arm during- anesthesia. The upper arm type of Duchenne- 
Erb invokes the deltoid, brachialis anticus, triceps, supinator 
longus, supinator brevis, and the infra-spinatus muscles. The 
patient is unable to addud the arm, and the forearm remains in 
a position of extension and pronation. The lower arm type of 
Klumpko involves the small muscles of the forearm and hand. 
with inability to move the hand or fingers. 

Rigidity and Contracture. — In hemiplegia the paralysis of the 
arm is spastic and is followed in the course of time by permanent 
contracture. The elbow is maintained in a state of semi-flexion. 




Fig. 283.- Lipoma of arm. 



the wrist is flexed upon the forearm, while the arm is often closely 
apposed to the trunk. Spastic rigidity of the arm is often one of 
the earliest signs of chronic hydrocephalus. 

Movements. — In Sydenham's chorea the arms participate in the 
purposeless movements of the head and face. In this form of 
chorea there is no motor weakness; whereas in the so-called hemi- 
paralytic chorea, which is attended by similar purposeless move- 
ments of the arms, the muscular power is usually impaired. Preg- 
nant women occasionally exhibit similar purposeless movements of 
the arms in the so-called chorea gravidarum. 

In paramyoclonus multiplex there is frequently noted a sym- 
metrical, bilateral, clonic spasm of the muscles of the arms. The 
biceps, triceps, and deltoid muscles are involved. The paroxysm 



430 PHYSICAL DIAGNOSIS 

is characterized by a series of very rapid clonic contractions of 
symmetric groups of muscles in the two arms, the contractions 
often exceeding a hundred in a minute. Usually of very brief dura- 
tion, the paroxysm may in some cases last for several moments. 

Atrophy. — Atrophy of the muscles of the arm follows the paraly- 
sis of acute anterior poliomyelitis and brachial palsies, conditions 
which involve the lower motor neurone. 

Miner's Elbow. — In this condition there is a swelling overlying 
the olecranon bursa, produced by chronic bursitis of this struc- 
ture, which sometimes yields fluctuation on palpation. 



SKCTION III 
EXAMINATION OF THE LOWEB EXTREMITIES 



CHAPTER XXXI 
THE FOOT, LEG, AND THIGH 

THE TOES 

Gangrene of the toes is usually significant of diabetes, arterio- 
sclerosis, or Raynaud's disease. Gangrene of the toes is less 
frequently a sequence of frost-bite, local trauma, ergotism, or 
embolism in connection with cardiac disease. 

Perforating Ulcer. — The perforating ulcer, or Mai Perforante, 




Fig. 2S4. — Gangrene of toes. 

occurring with locomotor ataxia and rarely with diabetes, is a 
deep circular ulcer, usually situated upon the under surface of 
the great toe. 

Gout produces hot tense swelling of the metatarsophalangeal 
articulation of the great toe. which is very sensitive to pressure. 



THE FOOT 

Flat-Foot, pes planus, is a flattening or giving way of the nor- 
mal arch of the foot as a result of muscular paralysis, or ligamen- 

431 



432 . PHYSICAL DIAGNOSIS 

tons weakness from long standing or traumatism. Flat-foot is a 
sequence of rickets and infantile paralysis. Flat-foot is recog- 
nized by painting the sole of the foot with a colored fluid and 
causing the patient to stand upon a piece of paper, and noting 
whether an impression of the entire sole is left upon the paper. 

Club-foot or talipes is a permanent fixation of the foot in de- 
f ormit3 T . In talipes equinus the heel is drawn up in such a manner 
that the patient walks upon the ball of the foot or the toes. In 
talipes varus the foot is inverted, the patient walking upon its outer 
border. In talipes valgus the foot is everted and the patient walks 
upon the inner border of the foot. 

Enlargement of the foot with more or less distortion occurs 
in acromegaly, myxedema, and pulmonary osteo-arthropathy. 

Erythromelalgia. — In this condition the sole of the foot is very 
red and the seat of burning pain, which is made worse by walk- 
ing and is relieved by elevating the limb. 

THE LEG 

Bowing of the tibiae is most commonly due to rickets, but may 
also be noted in connection with osteitis deformans, mollities 
ossium, and cretinism. 

Nodes. — Red, shining nodes situated over the tibiae, which are 
very painful upon pressure are indicative of erythema nodosum, 
which is more frequently encountered here than in any other 
locality. 

Deep nodular swellings, situated upon the tibia are due to 
syphilis periostitis, while painless, non-inflammatory indurated 
areas distributed over the leg may be gummata. 

Leg Ulcers may be due to varicose veins, but are often due to 
tertiary syphilis, especially if there are multiple annular ulcers 
situated nearer the knee than the ankle. 

Swelling of the Calves in children, associated with loss of mus- 
cular power and difficulty in rising to the erect posture, is indic- 
ative of pseudo-hypertrophic muscular palsy. 

Atrophy of the muscles clothing the anterior and outer aspects 
of the leg is a sign of progressive muscular atrophy. 

Varicose Veins. — Varicosities of the veins of the leg are indic- 
ative in some instances of prolonged standing, or the pressure of 
a pregnant uterus or tumor within the abdomen upon the vessels 
returning blood from the lower extremity. 



EXAMINATION OF THE LEG 



433 



Kernig's Sign. — In acute meningitis it is impossible to fully 
extend the leg upon the thigh. To elicit Kernig's Sign the patient 
should be placed upon the back with the thigh flexed to a right 
angle with the body. An effort is then made to extend the leg, 
bringing it in a line Avith the thigh. In the presence of meningitis 
it is difficult or impossible to extend the leg because of the 





Fig. 285. — A case of rickets. 
(From Woolley.) 



Fig. 286. — A case of rickets. 
(From Woolley.) 



marked flexor contracture of the hamstring muscles. In diag- 
nosing meningitis by means of this sign it is necessary to exclude 
sciatica, old contractures, myositis, and tuberculous disease of 
the knee joint. 

Charcot's Joint. — In the course of locomotor ataxia not un- 
commonly as a result of trophic disturbance the knee-joint assumes 



434 



PHYSICAL DIAGNOSIS 




Fig. 287. — A case of rickets. (From Woolley.) 




Fig. 288. — Showing extreme case of bow-legs. (From Woolley.) 



EXAMINATION OF THE LEG 435 

an enormous size, due to chronic inflammation of the synovial lin- 
ing of the joint, which later progresses to the bone itself. The 

enlargement of the joint is always considerable and may become 
enormous. Early in the case the enlargement is due to effusion 
in the joint, but later it is produced by true osseous overgrowth. 
Pain is slight or is entirely absent. Usually affecting the knee- 




Fig. 289. — Varicose ulcer of leg. (From Eisendrath.) 

joint, the condition may involve the hip-joint, and less com- 
monly the smaller articulations. 

Housemaid's knee, produced by chronic bursitis of the prepa- 
tellar bursa as a consequence of persistent pressure upon the 
bursa incident to occupation, is characterized by effusion into 
the knee-joint, the effusion pushing the patella upward before it. 
Fluctuation can sometimes be obtained. 



436 PHYSICAL DIAGNOSIS 

THE THIGH 

Edema of the thigh, affecting the leg and foot as well possesses 
definite significance depending upon whether it is nni-lateral or 
bi-lateral. Thus, edema of one lower extremity may result from 
varicose veins or thrombosis of the femoral vein. Bi-lateral edema 
points to cardiac insufficiency or hepatic disease producing gen- 
eral anasarca. 

A chronic swelling of the lower end of the femur is often due 
to osteo-sarcoma of that bone. 

Intermittent Claudication. — In subjects of arterio-sclerosis an 
intermittent lameness may result from deficient circulation to the 
muscles of the thigh. 

Inguinal Adenitis. — Enlarged glands in the inguinal region may 
indicate venereal disease. In gonorrhea and .chancroid the 




Fig. 290. — Osteosarcoma of femur. 

glands are matted and tend to suppurate, whereas in syphilis the 
glands are only moderately enlarged, are hard, and discrete. In- 
guinal adenitis of long standing is suggestive of tuberculous disease 
of the hip or knee, or Hodgkin's disease. In malignant disease of 
the genitalia there is early inguinal adenitis. 

Swelling in Scarpa's Triangle. — A swelling in this portion of 
the thigh may be due to femoral hernia, or psoas abscess, the lat- 
ter always occupying a position external to the femoral vessels. 

Osteitis Deformans, (Paget 's Disease). — Osteitis produces bow- 
ing of the bones of the thighs, with a consequent diminution of 
the stature. The head in this disease is characteristically de- 
formed, and the contour of the thorax and abdomen is altered. 

Osteomalacia, in its evolution is characterized by bowing of the 
bones of the lower extremity, produced by softening and rarefac- 
tion of the osseous structures peculiar to this disease. 



EXAMINATION OF THE THIGH 437 

Rickets. — In advanced rickets there is usually notable bowing 
of the bones of the lower extremities, leading to "bow-legs" or 
"knock-knees." In addition there are symmetrical swellings at 
the epiphyses of the long bones. 

Pulmonary Osteo-Arthropathy. — In this disease the extremi- 
ties of the long bones of the lower extremity, particularly of the 
tibiae, participate in the chronic enlargement which character- 
izes the disease. 

Phlegmasia alba dolens, resulting from thrombosis of the 
femoral vein, produces swelling and edema of the thigh, with 
marked tenderness upon manipulation. The usual cause is puer- 
peral sepsis, but this condition is also a not infrequent complica- 
tion of typhoid fever. 

Paralysis. — Paralysis of one leg if spastic is usually a part of 
a hemiplegia, but may rarely be due to a cortical lesion involving 
the leg center. Flaccid paralysis of one leg is the result of pres- 
sure neuritis, chronic lead poisoning, or anterior poliomyelitis. 

Paralysis of both legs, paraplegia, may result from a cerebral 
lesion, as is the case in Little's disease, or may be due to trans- 
verse myelitis, disseminated sclerosis, or the late stages of loco- 
motor ataxia. 



PART IV 
EXAMINATION OF THE NERVOUS SYSTEM 



SECTION I 
MOTOR AND SENSORY PHENOMENA 



CHAPTER XXXII 
STATION, GAIT, AND MUSCULAR POWER— TREMOR 

Introduction. — The sources of the nervous impulses which ini- 
tiate muscular movements reside in certain specialized cells of 
the cerebral cortex lying anterior to the fissure of Rolando, in 
the nuclei of the cranial nerves at the base of the brain, and in 
the anterior horns of the spinal cord. The experimental work 
of Hughlings Jackson, Hitzig, Ferrier, and Horsley has demon- 
strated that the motor path from the cerebral cortex to the volun- 
tary muscles comprises two segments, or neurones; namely, the 
upper motor neurone, extending from the cerebral cortex to the 
anterior cornual cells, and forming synapses with the cells of cer- 
tain of the nuclei of origin of the cranial nerves; and the lower 
motor neurone, which extends from the anterior cornual cells to the 
muscle in question. 

The axis cylinders of the upper motor neurone, arising from 
cells of the cerebral cortex in the motor area pass downward into 
the white substance of the brain to form the corona radiata. 
They are collected into a compact bundle of fibers which tra- 
verse the internal capsule between the basal ganglia, constituting 
the genu and anterior two-thirds of the posterior limb of this 
structure. Emerging from the internal capsule, the upper motor 
neurone enters the crus cerebri, some fibers at this point crossing 
to the opposite side to form synapses with the cells of the nucleus of 
origin of the oculomotor nerve. The upper neurone traverses the 
crus and pons, distributing .fibers to all of the motor cranial 

438 



STATION, GAIT, MUSCTTLAB POWER 439 

nerves of the opposite side and a few fibers to the same 
nerves on the same side, and enters the anterior portion of the 
medulla oblongata to form the pyramid. In the medulla the 
greater number of the fibers constituting the upper motor neu- 
rone cross to the opposite side, forming the decussation of the 
pyramid. These fibers enter the lateral portion of the spinal 
cord as the crossed pyramidal tract, while the smaller number of 
fibers, which did not cross at the decussation, pass down the 
anterior portion of the cord as the direct or uncrossed pyramidal 
tract. The fibers of the crossed and direct pyramidal tracts 
terminate at various levels of the cord by forming synapses with 
the anterior cornual cells, the direct pyramidal fibers crossing in 
the anterior white commissure before forming this junction. 
Thus the upper motor neurone terminates by effecting a junc- 
tion with the cells of origin of the lower motor neurone. It is to 
be noted that impulses arising in the cerebral cortex are all trans- 
mitted to the opposite side of the spinal cord by the upper motor 
neurone. 

The axis cylinders of the lower motor neuront arise in the an- 
terior cornual cells and emerge as the anterior spinal nerve roots 
to form the peripheral nerves which supply muscles on the same 
side of the body. They do not cross. 

The sensory conducting system comprises three neurones. The 
first sensory nt urone is derived from the ganglia upon the posterior 
nerve roots, the axis cylinders of which divide in a T-shaped 
manner, the longer division going to the peripheral sensory nerve, 
while the shorter branch enters the posterior horn of the spinal 
cord and divides into a long ascending and a short descending 
branch. The longer, ascending branches from this source ascend 
in the posterior columns of the cord to terminate in cells of the 
gray matter of the same side of the cord or to ascend to the 
nucleus gracilis and nucleus cuneatus of the medulla. 

The second sensory neurone arises from the medullary cells or 
the medullary nuclei, form the arcuate fibers, and terminate in 
synapses about the cells of the median and lateral nuclei of the 
optic thalamus of the opposite side. 

The third sensory neurone takes origm from the nuclei of the 
optic thalamus and terminates in the sensory areas of the cerebral 
cortex. 

Gross lesions involving the integrity of the upper motor neu- 
rone in any portion of its course from the cerebral cortex to the 



440 PHYSICAL DIAGNOSIS 

anterior horns of the cord produce spastic paralysis of definite 
portions of the muscular system; since the regulating or govern- 
ing impulses descending from the cerebral cortex are in abeyance 
and the constant tonic impulses from the anterior cornual cells 
are uncontrolled. Lesions of the lower motor neurone, on the 
contrary, produce flaccid paralysis, with atrophy of the muscle, 
as trophic impulses have their origin in the anterior cornual 
cells. 

The Station. — The station is the attitude of the patient when 
standing at ease in the erect posture. In testing the station the 
patient should be directed to stand with the feet closely ap- 
proximated, and the test should be made first with the eyes 
open and then with the eyes closed. A normal person while 
undergoing this examination will frequently sway slightly from 
side to side, and in cases of muscular weakness, either from ex- 
hausting disease or from neurasthenia, the swaying is more 
marked. But when the swaying movement becomes so extreme 
that the patient is in danger of falling if not supported, the sta- 
tion becomes pathological. Thus in tabes dorsalis the patient 
with feet closely approximated and the eyes closed sways ex- 
cessively and if not supported is apt to fall (Romberg's sign). 

The Gait. — In many nervous diseases the gait is characteristic 
and gives at once a clue to the correct diagnosis. In observing 
the gait of a patient who is suffering with an organic nervous 
disease the clothing should be removed from the lower extremi- 
ties so that the phenomena attending locomotion may be clearly 
observed. 

The Spastic Gait. — In spastic diplegia due to lesions in the 
lateral pyramidal tracts the lower limbs are stiff owing to an in- 
ability to bend the knees, so that the patient progresses by means 
of short steps, the toes scraping along the floor. The toes of the 
shoes are worn excessively. The presence of a marked ankle 
clonus on both sides communicates a general tremulousness to 
the entire carriage of the patient, who is apt to stumble over 
slight obstacles and fall. 

The Hemiplegia Gait. — The hemiplegic gait is merely a uni- 
lateral spastic gait, the spastic limb during progression de- 
scribing an arc of a circle while the sound limb supports the 
weight of the body. In spastic cerebral paraplegia, or double 
hemiplegia, both limbs describe the arc of a circle during pro- 
gression, each foot in turn being swung outward and planted in 
front of the other with the production of the cross-legged or 



STATION, GAIT, MUSCULAR POWER 



441 



"scissor" tfait ; the trunk and upper limbs meanwhile being 
jerked about from side to side in the effort to move the spastic 
member's forward. 

The Steppage Gait. — Patients with multiple neuritis with foot 
drop, or with lesions of the lumbosacral region of the spinal 
cord exhibit the steppage gait, a mode of progression in which 




Fig. 291. — Little's disease. (Infantile spastic diplegia.) 




Fig. 292. — Little's disease. (Infantile spastic diplegia.) 



each foot is alternately raised high, the toe thrown upward, 
the foot striking the ground forcibly, as if the patient Avere con- 
tinually stepping over obstacles in his path. A uni-lateral 
steppage gait accompanies paralysis of the external popliteal 
nerve. 

The Ataxic Gait. — The ataxic or tabetic gait occurs typically 
in tabes dorsalis, a very similar gait being observed in Fried- 



442 PHYSICAL DIAGNOSIS 

reich's ataxia, and in tumor of the posterior columns of the 
cord. The patient walks on a very broad base, swaying from side 
to side. The foot in progression is raised suddenly from the 
floor, is thrown forcibly forward, and thrown forcibly down "in 
flail-like fashion," the heel usually striking the floor first. The 
patient keeps the eyes fixed steadily upon the floor before him 
in the effort to guide his onward course. He is unable to sud- 
denly stop or start on command or to turn suddenly and re- 
trace his course. Similar ataxia in the upper limbs is demon- 
strable in the inability of the patient to touch the finger-tip to 
the nose, or to accurately approximate the finger-tips with the 
arms before the body. 

The Festinating Gait. — In paralysis agitans the patient moves 
forward with the body inclined somewhat forward, advancing 
with short, shuffling steps which become progressively faster as he 
crosses the room. When ordered to turn, the entire body is turned 
en masse. This type of locomotion constitutes the so-called pro- 
pulsion. Retropulsion may often be elicited in these patients. 
If the patient is quickly pulled backward, and, indeed sometimes 
on merely looking upward, he tends to run backward with short, 
shuffling steps, although the body is invariably inclined forward. 

The Cerebellar or Vertiginous Gait. — In cerebellar disease as- 
sociated with severe vertigo the patient progresses in a very ir- 
regular course, often lurching from side to side. Quite fre- 
quently the patient exhibits a tendency to reel in a fixed direc- 
tion, forward, backward, or to one side. This type of progres- 
sion occurs with uni-lateral cerebellar lesions. In uni-lateral 
cerebellar tumors the head is not infrequently inclined toward 
opposite side, while the face is turned slightly toward the side 
of the lesion. 

Muscular Power. — A rough estimate of the muscular power 
may be made by the "resistance method," the patient being di- 
rected to perform the functon of a given muscle, while the ex- 
aminer endeavors to resist the movement and gauges the amount 
of power required in the effort. Variations in muscular power 
range from simple weakness to complete loss of power or pa- 
ralysis. Paralysis may be complete or partial, in which latter 
event it is termed paresis. Paralysis may be spastic, when the 
paralyzed limb is rigid and the muscles unyielding to passive move- 
ment, or flaccid, when the muscles are soft and pliable. Paraylsis 
may affect one limb, when the condition is termed monoplegia; it 



STATION, GAIT, MUSCULAR POWER 443 

may affect one cut ire side of the body, when it is termed hemi- 
plegia; or all four limbs may be involved, when the condition is 
designated diplegia. 

Tremor. — Coarse shaking movement of the muscles of the 
hand upon voluntary muscular effort (intention tremor), ac- 
companies disseminated sclerosis. On the contrary, the fine 
"pill-rolling" tremor of paralysis agitans is inhibited by volun- 
tary movement. Convulsive tremors involving a small or lim- 
ited group of muscles are observed in Jacksonian epilepsy, while 
fibrillary twitchings accompany progressive muscular atrophy. 
A hemichorea may persist for years as a residual sign of cere- 
bral hemorrhage. 



CHAPTER XXXIII 
SENSOEY PHENOMENA— THE REFLEXES 

Tactile Sensation. — The acuity of tactile sensibility is tested by 
gently touching the cutaneous surface in various regions with a 
feather or a small wick of cotton, while the patient's eyes are 
closed. A normal person can state the instant when the skin is 
touched and, in a general way, the nature of the fabric with 
which it is in contact. While the readiness with which the tac- 
tile sensations are registered is a reliable index to the integrity 
of the sensory pathway, allowance must be made in certain in- 
stances for the degree of natural intelligence of the patient under 
examination. Tactile sensibility is impaired (hypesthesia) in 
compression or partial lesion of the sensory pathway; it is ab- 
normally acute (hyperesthesia) in functional irritability of the 
sensory tract; and it is abolished (anesthesia) in organic disease 
of the dorsal columns of the cord. 

Pressure Sense. — The pressure sense is investigated by noting 
the ability of the patient to appreciate minor variations in pres- 
sure, when cubes of uniform size, but of varying weight, are 
placed upon the surface under examination. During this exam- 
ination muscular sensation must be eliminated by placing the 
limb upon a firm, unyielding surface; and temperature sense 
must be excluded, as extremes of temperature have a tendency to 
impair the nicety of the pressure sense. Variations in the acuity 
of the pressure sense have the same significance as have varia- 
tions in the tactile sense. 

Sense of Temperature. — The entire cutaneous surface is sup- 
plied with specific "heat spots" and "cold spots," which are 
supplied by nerve endings for the appreciation of these varie- 
ties of sensation. Hence the power of discriminating variations 
in temperature may be retained, while tactile sensation is tempo- 
rarily abolished. Thus, compression of the ulnar nerve, which 
causes a marked diminution of tactile sensibility over the dis- 
tribution of the nerve, does not involve the temperature percep- 
tion in this area. As a general rule, the portions of the body 
which are habitually clothed are more sensitive to thermic varia- 
tions than are the exposed portions of the integument. 

444 



SENSORY PHENOMENA — THE REFLEXES 445 

The sense of temperature may be tested by applying to the 
area under examination alternately test-tubes containing water 
at temperatures slightly above and below thai of the body. In 
organic disease of the spina] cord, as syringomyelia and in lesions 
of the medulla and pons, as hemorrhage, tumor, or softening, the 
perception of temperature may be impaired (thermo-hypesthe- 
sia) ; may be intensified (thermo-hyperesthesia) ; or it may be 
abolished (thermo-anestbesia) in the area under investigation. 

Sense of Pain. — It is generally agreed that there are specialized 
"pain spots" distributed universally over the cutaneous surface, 
which are supplied with special nerve endings; and that the sen- 
sation of pain is not merely due to over-stimulation of the nerve 
endings of tactile or temperature sensation. The sense of pain is 
tested by pricking the skin Avith a fine needle. In certain in- 
stances the pain sense is perverted, a stimulus applied to one limb 
causing a painful sensation in the opposite limb. Diminution of 
the perception of pain (hypalgesia) is encountered in compres- 
sion and partial lesions of the sensory nerves; increased sensi- 
bility to pain (hyperalgesia) accompanies functional irritation of 
these tracts; while abolition of the pain perception (analgesia 
signifies a total destruction of the sensory trad. 

Muscular Sense. — Muscular sense is the sense by means of 
which judgments are formed as to the weighl of articles which 
are lifted, by which the patient is aware of the position of cer- 
tain portions of the body without the aid of the eyes, and by 
which he is enabled to maintain the standing posture without 
conscious effort. 

The muscular sense may be examined by directing the patient 
with the eyes closed to place the finger upon a certain portion of 
the body, as for instance, the tip of the nose; it is also tested by 
directing the patient to stand upright with the feet closely ap- 
proximated and with closed eyes. Thus, in organic disease of the 
nervous system the disturbance of the muscular sense, with simi- 
lar tactile sensory disturbance, is responsible for Romberg's sign. 

The muscular sense is also investigated by noting the percep- 
tion of active and passive movements of the limbs. Thus, the 
patient is directed to perform various movements with the limbs, 
such as describing a semi-circle on the floor with the toe, or 
touching the knee with the ankle of the opposite limb. In test- 
ing the perception of passive movements, the limb of the patient 
is slowly moved while the eyes are closed, and he is asked to 



446 PHYSICAL DIAGNOSIS 

indicate the range of the movement and the new position of the 
limb. 

Stereognostic Sense. — Stereognostic sensibility is the faculty 
by which objects placed in the hand are recognized by their pal- 
pable shape and consistence. An abolition of this sense (astere- 
ognosis) is often indicative of a lesion involving the superior 
parietal lobule of the brain. 

The Reflex Arc. — The reflex arc comprises an afferent or sen- 
sory neurone, which conducts impulses to an intermediate cell 
station, and an efferent neurone over which the cell station or 
medullary center discharges motor impulses in response to the sen- 
sory stimulus which is conveyed to it by way of the afferent 
sensory neurone. The entire sequence of changes constitutes a 
reflex act. In the case of the spinal reflexes the afferent neurone 
is represented by peripheral spinal sensory nerve with its root 
ganglion, the intermediate cell station by the gray matter of the 
spinal cord, and the efferent neurone by the motor nerve arising 
from the cells of the anterior horn of the cord. Spinal reflexes 
occur without any intervention on the part of the cerebrum, 
the different segments of the cord acting independently; but 
there are governing fibers descending in the pyramidal tracts 
from the cerebral cortex which modify and may voluntarily abol- 
ish or inhibit the spinal reflexes. 

The Patellar Tendon Reflex (Knee-jerk). — If the patient is in 
a sitting posture, to elicit this reflex the leg is flexed at a right 
angle with the thigh, while the patellar tendon is struck a rapid 
light blow with a percussion hammer. If the patient is bed-rid- 
den, the reflex may be elicited by raising the leg from the bed by 
means of a hand placed beneath the knee-joint while the blow 
is delivered. During the examination every effort should be made 
to distract the attention of the patient from the procedure, in or- 
der to prevent cerebral inhibition of a normal reflex. If the pa- 
tient is very self-conscious and the reflex consequently is elicited 
with difficulty, Jendrassik's reinforcement may be resorted to. 
The patient is directed to lock the hands and pull, meanwhile 
keeping his eyes fixed upon the ceiling. 

Exaggeration of the patellar tendon reflex is indicative of disease 
between the level of the reflex arc and the cerebral cortex, whereby 
the governing impulses from the cerebrum are interrupted. Such 
a condition arises in spastic spinal paraplegia, amyotrophic lateral 
sclerosis, cerebral hemorrhage, and disseminated sclerosis. 



SENSORY PHENOMENA — THE REFLEXES 447 

Abolition of the patellar tendon reflex is indicative of a break 
in the reflex arc due to disease of the sensory neurone, posterior 
root zone, or anterior root cells. Such lesions arise during tabes 
dorsalis, anterior poliomyelitis, peripheral neuritis and trauma to 
the cord a1 the site of the reflex arc. 

Tendo-Achilles Reflex. — This reflex is elicited by directing the 
patient to kneel upon a chair, and, rendering the tendon taut by 
moderate dorsal flexion of the foot, whereupon the tendo-Achilles 
is struck sharply, when normally sudden extension of the foot is 
produced. The significance of variations in the response are the 
same as those for the knee-jerks. 

The Plantar Reflex. — When the sole of the foot is stimulated by 
stroking With a match or probe, plantar flexion of all the toes 
ensues. In upper motor neurone involvement, instead of the uni- 
form plantar flexion of the toes, the greal toe is extended while 
the remaining toes are flexed I Babinski's sign). 

Ankle Clonus. — To elicit this clonus the examiner grasps the 
calf of the leg in the palm of the left hand, while with his right 
hand he exerts pressure upon the fore pari of the sole of the foot, 
thus maintaining the foot in a position of dorsal flexion. In dis- 
ease of the upper motor neurone, as disseminated sclerosis, cere- 
bral hemorrhage, or spastic paraplegia, a series of regular, rhyth- 
mic contractions of the calf muscles ensue, which continue until 
the museles are temporarily exhausted. 

Patellar Clonus.— The patellar clonus is elicited by placing the 
limb in a position of full extension and grasping the patella be- 
tween the thumb and lingers and exerting strong downward pres- 
sure upon the quadriceps extensor tendon. In disease of the up- 
per motor neurone a series of rhythmical eontractions are set up 
in the quadriceps extensor analogous to that obtained in the 
ankle clonus. 



CHAPTER XXXIV 
THE CRANIAL NERVES 

The twelve cranial nerves are paired nerves, resembling in this 
respect the spinal nerves. The first two cranial nerves, however, 
the olfactory and optic, differ so markedly in their anatomic and 
.physiologic features from the other cranial nerves as to have been 
compared to accessory lobes of the brain. The centers of the cranial 
nerves lie in a mass of gray matter along the floor of the fourth 
ventricle, the aqueduct of Sylvius and the floor of the third ven- 
tricle, representing an upward continuation of the central gray 
matter of the spinal cord. 

Lesions involving the cranial nerves may be situated in the 
cerebral cortex or the fibers descending from the cortical cells 
to the deep origin of the cranial nerves (supranuclear lesions), 
may involve the nucleus alone (nuclear lesions), or may involve 
only the peripheral portion of the nerve (infranuclear lesions). 
While supranuclear and infranuclear lesions not infrequently 
manifest themselves in derangements of a single cranial nerve, 
the nuclei of origin of these nerves are so closely aggregated be- 
neath the floor of the fourth ventricle and sylvian aqueduct that 
a lesion in this situation usually involves the nuclei of several 
cranial nerves, with the consequent production of more general 
manifestations. 

THE OLFACTORY NERVE 

The center for the olfactory nerve is probably situated in the 
uncinate and hippocampal gyri, with communicating fibers to the 
cerebral cortex, optic thalamus, and internal capsule. The ter- 
minal branches of distribution of the nerve are distributed to the 
superior turbinated bodies and the upper portion of the septum, 
whence they pass upward to the dilated anterior extremities of 
the optic tracts, the optic bulbs. 

The integrity of the olfactory nerve is tested with familiar 
odorous substances, such as the oils of peppermint or cloves, co- 
logne water or cinnamon. Ammonia or acetic acid should not be 
employed, as they are known to affect the trigeminal nerve. In 

448 



THE CRANIAL NERVES 449 

applying the test the substance is applied to each nostril sepa- 
rately and in turn, with the eyes of the subject meanwhile closed. 

The sensibility of the nerve may be diminished or abolished 
by local or central conditions. The most frequent cause for loss 
of the sensibility of the nerve lies in local nasal conditions, as 
coryza or polypi. In the aged there is often a normal diminution 
in the acuity of the perception and differentiation of odors. More- 
over, after prolonged or excessive stimulation the sense of smell 
becomes blunted or diminished for the time being. 

Marked diminution in the acuity or abolition of the olfactory 
sense, anosmia, is significant of many intracranial conditions. In 
congenital absence of the olfactory nerves it is a natural se- 
quence. Compression of the nerve trunk by aneurism of the mid- 
dle cerebral artery, by chronic hydrocephalus, by a cerebral tumor 
oi- abscess, or irritation by a meningitis chiefly localized to the 
anterior fossa of the skull results in anosmia. Destructive lesions 
of the bulb or tract, caries of the cranial bones, or injury incurred 
during basal fracture, cause anosmia. Similar loss of the olfac- 
tory sense is noted in tabes dorsalis and paresis. 

Perversions of the olfactory sense, parosmia, are not infrequently 
met with in cases of tabes dorsalis, during the aurae of epileptic 
seizures, and in various mental disorders. 

Hyperacuity of the sensibility of the nerves, hyperosmia, occurs 
in neurotic and insane patients. The acuity of this special sense is 
often markedly increased in persons following certain occupations 
and in blind patients. 

THE OPTIC NERVE 

The optic nerve and retina have been aptly called an accessory 
lobe of the brain. The visual fibers of the optic nerve take origin 
from centers upon the mesial aspect of the occipital lobe of the 
cerebrum in the region of the calcarine fissure and the cuneus 
on either side. These are the higher centers of vision. From 
these centers the right and left optic radiations respectively pass 
forward and form synapses with fibers terminating in the ex- 
ternal geniculate bodies and the corpora quadrigemina of the two 
sides of the brain. From these centers fibers arise Avhich form fhe 
optic. tract, a band of fibers which courses around the crura cere- 
bri on either side to meet anteriorly and form the optic chiasm, 
where a partial decussation of the fibers occurs, the right optic 
tract distributing visual fibers to the right half of each retina, 



450 PHYSICAL DIAGNOSIS 

and the left tract supplying similar fibers to the left half of each 
retina. Lesions involving different portions of these tracts pro- 
duce characteristic lesions which aid in localizing the individual 
lesion. 

The light fibers, the fibers of the optic nerve and retina which 
react to light stimuli, arise in the retina, whence they pass back- 
ward in the optic nerve, undergoing partial decussation at the 
chiasm, and proceed along the optic tracts to the external genicu- 
late bodies and corpora quadrigemina, whence they pass to the 
oculomotor nucleus beneath the floor of the aqueduct of Sylvius 
by way of the fasciculus sublongitudinalis. Thus the reflex arc of 
the light reflex is composed of an afferent limb, a substation in the 
midbrain, and an efferent limb, which will be considered in detail 
under the examination of the third cranial nerve. 

Vision. — The acuity of vision normally is tested with the ordi- 
nary Snellen Test Type. 

Amblyopia. — Amblyopia, dimness of vision, which is not due to 
errors of refraction, may result from the excessive use of tobacco 
or alcohol. Amblyopia may also arise during diabetes mellitus, or 
it may signify impending uremia in a nephritic patient. The in- 
gestion of certain drugs, as quinine or the salicylates, may induce 
amblyopia. 

Hemeralopia (Day -Blindness). — Hemeralopia, a condition in 
which the vision is impaired during the day, but improves on dark 
days or at night, is often part-and-parcel of tobacco amblyopia. 
It may also signify chronic optic neuritis from intracranial causes 
or intoxications, or chronic retinitis from a similar cause. 

Nyctalopia (Night-Blindness). — Nyctalopia, characterized by im- 
perfect vision in subdued light, is often the result of frequently re- 
peated exposures to strong illumination. In other instances it is a 
congenital defect of the visual apparatus. 

Color Vision (Color-Blindness). — The inability to differentiate 
between differences in the gradation of colored fabrics is in most 
instances an inherited defect. Acquired color-blindness occurs, 
however, as the result of toxic amblyopia, optic neuritis, or as a 
rare result of trauma to the cranium. In testing for color-blind- 
ness, the Holmgren or Thomson test should be employed. 

Holmgren Test. — In applying this test the patient is given a 
skein of wool of a light-pink color and directed to select from a 
mass of similar skeins of various colors and shades of colors all 
those which nearly match the color of the selected test skein. 



THE CRANIAL NERVES 451 

[f the color vision is impaired, skeins of varying colors, gray, 
green, pink, and brown, will be selected indiscriminately. If the 
subject fails on the pink skein, a pure green skein is selected for 
a conl rol. 

Thomson's Test. — In this test a stick to which numerous bundles 
of yarn of various colors are attached is employed. The colors 
have corresponding numbers, the odd numbers being green and 
the even numbers corresponding to the confusing colors. The 
color vision is tested with a pale green test skein, the patient being 
required to match it with ten tints on the rod. The selection of 
skeins with even numbers reveals the patient's inability to dis- 
criminate between the different shades and colors. A control 
test should be made with red and old-rose skeins as test colors. 

Field of Vision. — The dimensions of the field of vision in each 
eye is best determined by a perimeter; but as this instrument is 
usually not available, other methods of testing the field of vision 
must be employed. A rough but sufficiently accurate estimation 
of the size of the field of vision may be made by the following 
simple procedure. 

The patient is seated in a straight chair with his back' toward 
the source of illumination, the examiner occupying a chair facing 
the patient, and approximately three feet from him. In testing 
the left eye, the right eye of the patient is covered with a bandage; 
the examiner closes his right eye, at the same time fixing his left 
eye upon the pupil of the left eye of the patient. The examiner, 
beginning well beyond the limits of vision for both patient and 
himself, slowly moves his hand inward until the patient first 
sees the finger-tips. This maneuver is repeated in all the meridians 
of the visual field; and if the finger-tips become visible to the 
patient at the same instant they are apprehended by an examiner 
with a normal visual field, the patient's visual field is of normal 
extent; that is, is not contracted. If, on the contrary, the 
hand of the examiner must be brought nearer the visual axis than 
is required for the normal examiner, the visual field of the patient 
is contracted. 

Contractions of the visual field may be concentric or irregular. 
Concentric contraction is noted in many cases of hysteria, and also 
in glaucoma. Irregular or asymmetric contractions, represented 
by scotomata and hemianopia possess a varied significance. 

Scotomata are to be detected by passing small pieces of white 
and colored cardboard across the axis of vision while the patient 



452 PHYSICAL DIAGNOSIS 

fixes the eye under examination upon a designated objective point. 
Under these circumstances the patient is directed to state the 
point in the progress of the cardboard at which it becomes tem- 
porarily invisible. It is to be remembered that there is a physio- 
logical scotoma for light and color, corresponding to the blind 
spot of Mariotte, which must be eliminated in ocular examinations. 
An absolute scotoma, betrayed by the inability of the patient to 
recognize in the scotomatous field a white cardboard or light stimuli, 
is significant of grave destructive lesions, as optic neuritis or a 
lesion involving some portion of the optic tract. A relative or color 
scotoma, revealed by the inability of the subject to appreciate red 
and green cards in certain portions of the visual field, is usually 
the result of the excessive use of tobacco or alcohol, and gives a 
distinctly better prognosis than do the absolute scotomata. 

Hemianopia, obliteration or darkening of one-half of the visual 
field, is tested for clinically by the maneuver used for determin- 
ing variations in the extent of the visual field ; which, in the pres- 
ence of hemianopia reveals a darkening of one-half of the visual 
field. 

Hemianopia may be horizontal or vertical, homonymous or 
heteronymous, bi-temporal, bi-nasal or mixed, as the case may 
prove. 

The significance of hemianopia is a lesion involving the optic 
nerves, optic chiasm, or optic tract; and the site of the intra- 
cranial lesion is determined by the distribution of the hemianopic 
changes. In homonymous hemianopia the corresponding halves 
of the visual fields are obliterated ; as, for instance, the temporal 
half of the right retina and the nasal half of the left retina. 
Such an ocular finding constitutes right lateral homonymous 
hemianopia, the significance of which is a lesion involving the 
right optic tract alone. Similarly a bi-temporal hemianopia sig- 
nifies a lesion involving the central portion of the chiasm, whereas 
a bi-nasal hemianopia is produced by lesions at both extremities 
of the chiasm, but sparing the central portion of this structure, a 
condition which rarely occurs. Transitory hemianopia sometimes 
occurs with hysteria and migraine without anatomic change in 
the tract. 

Wernicke's Pupillary Reaction. — If, in a case of hemianopia, 
with the patient seated in a darkened room, a thin ray of light 
from an ophthalmoscopic mirror is projected into the orbit upon 
the hemianopic retinal area at an angle of 40 to 60 degrees from 
the visual axis, myosis may or may not result. In hemianopias 



THE CRANIAL NERVES 453 

in which the causative lesion is situated in the optic tract anterior 
to the corpora quadrigemina no pupillary reaction will occur, as 
the reflex arc for the light reflex is broken; but if the lesion is 
situated posterior to the corpora quadrigemina, the myosis occurs, 
as the reflex arc in this instance is not disturbed. This test, de- 
pending partially on the action of the third cranial nerve, is em- 
ployed to further localize lesions productive of hemianopia. 

THE THIRD, FOURTH, AND SIXTH CRANIAL NERVES 

These nerves, which control the pupillary reactions, and the 
movements of the ocular muscles, are more profitably examined 
in unison than singly and individually. All three nerves arise 
from nuclei situated beneath the floor of the fourth ventricle 
and the aqueduct of Sylvius. The third cranial nerve (oculomo- 
tor) supplies fibers to the sphincter of the pupil and all of the 
ocular muscles except the external rectus and the superior oblique. 
The fourth cranial nerve (trochlear) supplies the superior oblique 
muscle of the eye. The sixth cranial nerve (abducent) supplies 
the external rectus muscle of the eye. 

Pupillary Reflexes. — Light Reflex. — The normal pupil when 
exposed suddenly to light stimuli responds by a reflex contraction 
of the iris. The light reflex may be elicited by shading the eyes 
with the hands whereupon, on suddenly uncovering one eye the 
pupillary contraction may be noted. This method of examination, 
however, is apt to prove fallacious, inasmuch as a reaction to ac- 
commodation is likely to be mistaken for a normal light reflex. 
This source of eiTor may be avoided by throwing a beam of light 
from an ophthalmoscopic mirror upon the shaded eye. or by test- 
ing similarly with the illumination from a small electric flash- 
light. In the absence of these instruments, the reflex may be 
elicited by exposing the pupil to the light of a burning match. 

The reflex arc involved in the light reflex consists of an af- 
ferent limb consisting of the optic nerve and tract, the corpora 
quadrigemina and fasciculus sublongitudinalis, a station repre- 
sented by the third nerve neucleus, and an efferent limb com- 
prising the third cranial nerve, the ciliary ganglion and ciliary 
nerves to the sphincter pupilke. 

A sluggish reaction to light or total abolition of the light re- 
flex signifies optic atrophy, partial or complete paralysis of the 
third cranial nerve, or degenerative changes in the ciliary gan- 
glion. It may signify compression of the optic tract or the fas- 



454 PHYSICAL DIAGNOSIS 

ciculus sublongitudinalis, which forms the connecting link be- 
tween the corpora qnadrigemina and the third nerve nucleus. 

Consensual Light Reflex. — If during the examination for the 
light reflex in one pupil, the pupil of the opposite eye is observed, 
while shaded and protected from the light stimuli applied to 
the opposite retina, it will be observed to react along with the 
pupil of the exposed eye. This phenomenon constitutes the con- 
sensual light reflex, and is due to the transmission of an im- 
pulse across the fibers which connect the two third nerve nuclei. 

Reaction to Accommodation. — When the range of vision is 
suddenly transferred from a distant objective point to an object 
near at hand, the pupils will be observed to contract and the 
eyes to converge, the reaction to accommodation. This reaction 
may be quickly tested by directing the patient to fix the gaze 
on a distant portion of the room, and then quickly to transfer 
the gaze to the finger of the examiner held near the face of the 
patient. Abolition of this reflex is due to third nerve paralysis. 

Argyll-Rooertson Pupil. — Abolition of the light reflex in one 
or both eyes with retention of the reaction to accommodation 
constitutes the Argyll-Robertson pupil, which is occasionally 
found in disseminated sclerosis, and very frequently in tabes 
dorsalis and paresis. Marina has shown this type of pupillary 
reaction to be caused by degenerative changes in the ciliary 
ganglion. In this pupil the pupillary margins are very fre- 
quently irregular, while the pupils are often somewhat myopic 
(spinal myosis) from disease of the cervical cord. Ultimately 
in tabes and paresis the pupil becomes immovably fixed, re- 
acting neither to light nor to accommodation. 

An opposite pupillary reaction, the pupil reacting to light, 
but failing to react to accommodation is often seen as a sequence 
of post-diphtheritic paralysis. 

Hippus. — Rapid, rhythmic, clonic contractions of the sphincter 
pupillae producing winking movements of the iris which are so 
gross as to be visible to the unaided eye (hippus) are frequently 
demonstrable in disseminated sclerosis, more rarely in hysteria, 
incipient acute meningitis, and epilepsy. 

Pupillary Unrest. — This phenomenon, which is a normal phys- 
ical finding, consisting of a regular narrowing and widening of 
the pupil, is so fine that it can only be demonstrated by means 
of the aid of a magnifying lens with the pupil brilliantly illumi- 
nated. Abolition of this normal pupillary unrest is one of the 
earliest signs of tabes dorsalis and paresis. 



THE CRANIAL NERVES 455 

Myosis. — Contraction of the pupil may result from irritative 
or destructive lesions. Irritative myosis is noted in the early 
stages of cerebral hemorrhage, in incipient brain tumors before 
sufficient pressure has been exerted upon the third nerve to 
cause paralysis, and in early acute meningitis and encephalitis. 
Paralytic myosis is seen in tabes dorsalis, the late stages of tabes 
of the cervical cord, and syringolyelia of this portion of the cord, 
leading to destruction of the pupil-dilating fibers. 

Mydriasis. — Irritative mydriasis is often due to irritation of 
the pupil-dilating center in the cervical cord from congestion, 
spinal meningitis, or tumor. Paralytic mydriasis may signify 
paralysis of the sphincter pupilhe, caused by disease of the third 
cranial nerve or ciliary ganglion, increased intracraneal pressure 
from brain tumor, or glaucoma. 

Strabismus (Squint). — In paralysis of one or more ocular 
muscles the normal axis of the eyeball deviates from its normal 
position, Avith the production of double vision or diplopia. A 
simple rule in the differentiation of the various ocular paralyses 
is that the affected eye is displaced by the unopposed antagonists 
to the side opposite to the usual traction of the paralyzed mus- 
cle, Avhile the -false image, the result of diplopia, is displaced in 
the direction of the line of traction of the paralyzed muscle (Pur- 
ves Stewart). 

Nystagmus. — Nystagmus is a rapid oscillation of the globe of 
the eye upon voluntary motion, usually in a horizontal direction, 
more rarely in a vertical direction, and very rarely it is rotary. 
It is a sign of value in disseminated sclerosis, epilepsy, chorea, 
brain tumor, tabes dorsalis, Friedreich's ataxia, and in some cases 
of chorea. Nystagmus may be the result of errors of refraction 
and may be noted in albinos. Miners are subject to a form of 
nystagmus, probably caused by the constant excursion of the 
eyes while working in the recumbent or stooping posture. 

Aural nystagmus, which may be produced experimentally by 
syringing the membrana tympani with water either above or 
below the temperature of the body, is regarded by Barany as 
the result of convection currents produced in the endolymph 
by the warming and cooling of the labyrinth. This "thermic nys- 
tagmus " is of value in testing the integrity of the vestibular nerve. 

Conjugate Deviation. — This comprises a concomitant deviation 
of both eyes toward the right or left, its significance being a lesion 
in the cerebral cortex, corona radiata, or internal capsule, above 
the crossing of the motor fibers. Thus, in cerebral hemorrhage 



456 PHYSICAL DIAGNOSIS 

the eyes are turned toward the side of the lesion and opposite 
to the side of the paralysis (Prevost's sign). In interpreting the 
sign it is to be remembered that the lateral movements of the eyes 
are governed by impulses arising in the cerebral cortex and passing 
by way of the corona radiata and internal capsule to the sixth 
nerve nucleus of the corresponding side, and thence across the 
posterior longitudinal fasciculus to the subdivision of the opposite 
oculomotor nerve nucleus which presides over the internal rectus 
muscle. Thus the conjugate lateral deviation of the eyes is caused 
by the simultaneous stimulation of the external rectus muscle 
on the side of the lesion and of the internal rectus muscle on 
the side opposite to the lesion, causing the patient to "look at 
his lesion." 

Ptosis. — Ptosis of the upper eyelid is revealed by the inability 
of the patient to elevate the lid. It is due to a lesion of the 
oculomotor nerve or nucleus. Isolated paralysis of the fourth 
cranial nerve is very rarely encountered, as this nerve usually 
participates in the palsies of the third and sixth nerves. In the 
rare instances of simple trochlear paralysis there is inability to 
rotate the globe downward and outward. Cerebral syphilis is the 
usual cause of the paralysis. 

Abducent Paralysis. — Isolated paralysis of the sixth cranial or 
abducent nerve is revealed by the inability of the patient to 
rotate the eyeball outward beyond the midpoint. Upon en- 
deavoring to follow the finger of the examiner the external rota- 
tion of the globe is interrupted at this point. 



TRIGEMINAL NERVE 

The trigeminal nerve has an extensive origin from the floor of 
the fourth ventricle, beneath the aqueductus sylvii, and the cer- 
vical spinal cord as low as the second cervical nerve. The fifth 
cranial is a mixed nerve, containing both motor and sensory 
fibers. The fibers constituting the sensory trunk have developed 
upon them the Gasserian ganglion which rests in a small fossa 
upon the petrous portion of the temporal bone. The motor root 
of the nerve supplies the masseters, the temporals, pterygoids, 
internal and external, mylohyoid, anterior belly of the digastric, 
the levator and tensor palati and tympani; and the azygos uvula?. 
The sensory trunk and Gasserian ganglion terminate in three 
trunks, the superior and inferior maxillary, and the ophthalmic, 
which distribute sensory fibers to the anterior two-thirds of the 



THE CRANIAL NERVES 457 

tongue, the mucous membrane of the buccal and nasal cavities, 
the salivary glands and teeth, the infraorbital and mandibular 
portions of the face, and the anterior portion of the scalp. 

Motor Paralysis. — Motor paralysis of the fifth cranial nerve is 
tested for by palpating the masseter and temporal muscles while 
the patient is directed to clench the teeth. In uni-lateral paraly- 
sis there is loss of the prominence with which the muscles stand 
out on the normal side. The patient is then directed to open the 
mouth and protrude the lower jaw. In uni-lateral paralysis the 
jaw is deviated toward the paralyzed side by the action of the 
sound external pterygoid muscle. 

Irritative lesions of the motor trunk or centers produces tris- 
mus, a mild form of tetanic spasm of the muscles of the lower 
jaw. Severe tetanic spasm of these muscles accompanies tetanus 
and strychnine poisoning. 

Sensory Paralysis. — Sensory paralysis involving the inferior 
maxillary division of the nerve produces anesthesia of the in- 
fraorbital region, which is tested for by drawing lightly across 
the face a small pledget of cotton loosely rolled or a camel's 
hair brush. 

Implication of the sensory fibers and the Gasserian ganglion 
are recognized by the very painful spasm, tic douloureux. 

In testing the sense of taste over the anterior two-thirds of 
the tongue the patient is directed to protrude the tongue and the 
examiner places on it various substances, such as quinine, sugar, 
salt, and citric acid, in powdered form. While the tongue is 
protruded the patient is required to point out on a printed card 
whether the sensation appreciated is sweet, sour, bitter, salty, or 
negative. The patient should not be allowed to make his decision 
after the tongue has been returned to the oral cavity as the flavors 
may be carried by the saliva to the posterior portion of the 
tongue which is supplied by the glossopharyngeal nerve. 



THE FACIAL NERVE 

The nucleus, or origin, of the facial nerve lies in the lower por- 
tion of the pons near the medullary junction, the root fibers of the 
nerve emerging at the lower border of the pons just internal to 
the point of emergence of the auditory nerve. In company with 
the auditory nerve, the facial nerve enters the internal auditory 
meatus of the temporal bone, transverses the aqueductus fallopii 
of that bone, and emerges from the stylo-ma stoid foramen. In 



458 



PHYSICAL DIAGNOSIS 



the aqueductus fallopii the nerve receives the chorda tympani, 
which contains taste fibers from the anterior portion of the tongue. 
After emerging from the stylomastoid foramen the nerve divides 




Fig. 293. — Facial paralysis. 




Fig. 294. — Facial paralysis.. (Church.) i, bilateral attempt to raise eyebrows; 2, bilateral 
attempt to close eyes; 3, smiling. (From Eisendrath.) 

into a number of diverging branches to supply the majority of 
the muscles of the head and face. 

Facial Paralysis. — The facial nerve is purely a motor nerve, ex- 
cept for the fibers it receives from the chorda tympani, destructive 



THE CRANIAL NERVES 459 

lesions in its center, or origin, or along its course through the 
aqueduct producing facial paralysis. In this form of paralysis 
the normal flexion folds disappear from the affected side of the 
face, the patient is unable to close the eye, which remains open 
and staring, is unable to whistle or smile, the angle of the mouth 
droops on the paralyzed side, while the opposite angle is drawn 
toward the healthy side. These changes constitute the typical 
Bell's palsy, which is due to a lesion of the nerve after its exit 
from the stylomastoid foramen, and which is often due to exposure 
to cold. 

If the lesion be situated in the aqueductus fallopii, in which 
situation the nerve is very susceptible to pressure from disease 
of adjacent structures, in addition to the signs of uni-lateral 
facial paralysis, the sense of taste is abolished over the dis- 
tribution of the chorda tympani. 

If the lesion involves the nucleus of origin of the nerve, or the 
root fibers or trunk prior to its entry into the internal auditory 
meatus, there is usually in addition to the other signs, hyper- 
acuteness of hearing due to paralysis of the stapedius muscle, 
which receives a branch of supply from the facial nerve as it 
traverses the aqueduct. 

In the case of a supranuclear lesion, a lesion involving the 
corona radiata and affecting only the supranuclear fibers, the 
main evidences of paralysis will be seen over the lower portion of 
the face, the muscles of the upper portion being affected to a 
minor degree, owing to the fact that the muscles of this upper 
region always act in unison and derive a nerve supply from both 
cerebral hemispheres. 

THE AUDITORY NERVE 

The auditory nerve is composed of two distinctly differentiated 
sets of fibers: (1) cochlear fibers, which subserve the function of 
audition; and (2) vestibular fibers, which supply the semicircular 
canals and preside over equilibrium. 

Deafness. — Impairment of the function of audition may be the 
result of local disease of the middle ear or of disease of the 
cochlear division of the auditory nerve. The acuity of hearing 
in the two ears may be determined by means of a watch, each 
ear being alternately occluded while the opposite ear is under 
examination, or by means of the vibrations of a tuning fork. In 
differentiathiff between middle ear deafness and nerve deafness 



460 PHYSICAL DIAGNOSIS 

the tuning fork should be applied to the midline of the forehead. 
Under these conditions, if the cause of the deafness lies in middle 
ear disease, the vibrations are most clearly audible in the diseased 
ear; whereas if it is a case of nerve deafness due to a lesion of 
the eighth nerve, the vibrations are audible only on the side of the 
sound ear. 

Tinnitus.: — Tinnitus aurium, or ringing in the ears, occurs 
with intracranial tumors and aneurism, temporary obstruction of 
the eustachian tube during acute colds, and during disease of the 
labyrinth. 

Vertigo. — Vertigo, or dizziness, when not of gastro-intestinal 
origin, signifies a cerebral or intracranial lesion such as tumor or 
aneurism acting upon the cerebellar centers of coordination or 
the afferent paths of the vestibular division of the auditory nerve. 
Tumors of the cerebellum are characterized by extreme vertigo 
and incoordination. Vertigo may be due to Meniere's disease or 
aural vertigo. 

The Barany Tests 

The tests of Robert Barany, which are based upon the experi- 
mental work of Flourens and Ewald, afford a valuable means 
of diagnosing and localizing intracranial lesions involving the 
integrity of the vestibular division of the auditory nerve. The 
causative lesion may operate upon the labyrinth, as in acute or 
chronic suppuration in this apparatus; upon the cerebellum, as 
in cerebellar abcess or tumor; upon the nucleus or origin or 
upon the trunk of the vestibular division of the auditory nerve. 

The tests consist in observing the character of the nystagmus, 
the manner in which the patient performs certain pointing tests, 
and the tendency on the part of the patient to fall in certain 
directions, (1) in the absence of external stimulation or depres- 
sion of the labyrinth; (2) when the labyrinth has been stimu- 
lated or depressed by the application of water at temperatures 
above or below that of the body or by the electric current; and 
(3) after the patient has been rapidly rotated in a revolving 
chair either toward the right or toward the left. 

The technic of the Barany tests has been variously modified, 
chiefly by Barany himself, to meet different clinical needs, the 
principles underlying the tests in all cases being the same. A 
very satisfactory routine method of examination is the fol- 
lowing: 

First Test. — Direct Objective Examination. — Without apply- 



THE CRANIAL NERVES 461 

ing any stimulus to the vestibular apparatus the nystagmus is 

noted and its character recorded. The nystagmus which is en- 
countered may be of labyrinthine or cerebellar origin. Laby- 
rinthine nystagmus comprises two components: a quick snap 
of the globe in one direction, which is followed by a slower re- 
turn to the resting position. Cerebellar nystagmus consists of 
two components, which are almost equal in time, but the pri- 
mary movement is slightly more rapid than is the secondary 
return to the resting state. In recording nystagmus the quick 
motion is always recorded. 

In the interpretation of nystagmic movements, it is to be borne 
in mind that the direction of the nystagmus in any given case 
conforms to the law of Flourens and Ewald that nystagmus 
arising from excitation of a single semicircular canal occurs 
only in the plane of that canal; that the relation between the 
movement of the endolymph in any canal and the direction of the 
consequent nystagmus is definite and constant ; and that re- 
versal of the direction of the movement of the endolymph causes 
a reversal of the direction of the nystagmus. Thus by a study 
of the nystagmic movements the extent of a labyrinthine lesion 
may be determined. Vestibular nystagmus may be horizontal, 
vertical, oblique, or rotary; thus, since irritation of a single 
semicircular canal can produce nystagmus only in the plane of 
the canal, and as the nystagmus caused by acute disease of the 
labyrinth does not occur in one direction, but in various direc- 
tions without corresponding exactly to the plane of any canal, 
we assume that all of the canals are involved in the acute sup- 
purative process. 

Having studied the nystagmus occurring without external 
stimulation of the labyrinth, the patient is directed to stand or is 
supported, with the eyes closed and the feet close together, and 
any tendency to fall and the direction of the fall, is recorded. 
According to the rule of Barany, "a person exhibiting vestibular 
nystagmus tends to move within the plane of the nystagmus, 
and to fall in the direction opposite to the quick nystagmic 
movement." 

The patient is next required to place the tip of the index 
finger in contact with the index finger of the examiner, to close 
his eyes and lower the arm to the side, and to replace his finger 
in contact with that of the examiner, the pointing test. Whereas 
a normal person can perform this test with a fair degree of ac- 
curacy, a patient with labyrinthine or cerebellar disease is liable 



462 PHYSICAL DIAGNOSIS 

to err in the direction of his lesion. The results of the first test 
in the presence of labyrinthine and cerebellar disease, as well as 
in the normal patient, are tabulated in the appended table, which 
has been compiled by Dr. C. E. Shinkle. 

Second Test. — The Caloric Tests. — The caloric or thermic tests 
consist in alternately stimulating and depressing the labyrin- 
thine apparatus by irrigating the external auditory canal with 
water above and below the temperature of the body. The tests 
are applied to the supposed side of the disease and to the sup- 
posedly normal side on alternate days to obviate the lingering 
effects of a former test. Instead of employing water, the same 
result may be obtained by the use of a galvanic battery, the 
anode being used for depression and the cathode for stimula- 
tion. In using the galvanic battery the patient retains one elec- 
trode in the hand while the other is applied to the' mastoid proc- 
ess, or the wall of the external auditory canal. 

The Cold Water Test — It has long been known that irrigation 
of the external auditory canal with water at the temperature of 
the body rarely produces discomfort, whereas irrigation with 
water at higher or lower temperatures produces nystagmus and 
often violent vertigo and vomiting. In the application of the 
cold water test the external auditory canal is irrigated with 
water below the body temperature, usually at a temperature of 
86° F. In the presence of a congested tympanic membrane, 
however, water of a lower temperature is required to produce a 
reaction. The water should be directed into the canal with but 
moderate force, preferably from a fountain syringe or a small 
glass funnel attached to a piece of catheter tubing. 

The Warm Water Test. — In this instance the external auditory 
canal is irrigated in a similar manner with water slightly above 
the body temperature, each meatus being tested on alternate 
days. The technic is the same as for the cold water test. 

The physical basis underlying the caloric tests consists in the 
establishment of convection currents in the endolymph under 
the influence of the cool or warm external applications. In the 
production of caloric nystagmus the horizontal and anterior ver- 
tical canals are principally influenced, as they are situated in 
close proximity behind the median tympanic wall, and are hence 
easily influenced by external thermic influences; whereas the pos- 
terior vertical canal, which is situated medially and internally 
to them, is less exposed to such stimuli. When, under the appli- 
cation of the cold and hot water tests, the specific gravity of the 



THE CRANIAL NERVES 463 

endolymph is raised or lowered, a relative change in the posi- 
tion of the contained endolymph of the semicircular canals is 
induced. Naturally, the principal direction of the shifting of 
the endolymph, depending on variations in its specific gravity, is 
upward and downward. Thus, with the head erect, during the 
application of the cold water test, the cooling of the endolymph 
in the horizontal semicircular canal, which is first exposed to the 
action of the external stimulus, does not lead to any endolym- 
phatic movement, as such movement is prevented by the horizon- 
tal postion of the canal. But, in the case of the anterior vertical 
canal, the outer or ampullary end, which points directly down- 
ward, is exposed to the cool water and a downward movement 
of the endolymph toward and through its ampulla is induced, 
leading to a rotary nystagmus toward the opposite side. 

If now the position of the head is reversed, the head being in- 
clined directly downward toward the floor, immediately after 
the application of the cold water test, producing in this manner 
a reversal of the current of the endolymph, the direction of the 
rotary nystagmus is naturally reversed, the nystagmus in this 
instance occurring toward the side of the ear which is syringed. 
Moreover, if the head immediately after irrigation of the external 
auditory canal is bent forward so that the face looks directly 
toward the floor, the nystagmus produced is entirely horizontal, 
for the reason that in this position of the head the chief endo- 
lymphatic movement occurs in the horizontal canal with a conse- 
quent purely horizontal nystagmus. 

The usual reactions to the caloric tests in labyrinthine dis- 
ease, cerebellar disease, and in the normal person, are tabulated 
in the annexed table. 

Third Test.— The Eolation Tests. — In these tests, the patient, 
seated on a revolving chair, is turned rapidly toward the right 
or left, or from and toward the side of the suspected lesion. Ten 
revolutions of the chair, which should consume about twenty 
seconds, are best adapted to elicit the reaction. At the comple- 
tion of the last turn the patient and chair are abruptly stopped. 
When we speak of turning the patient from left to right, we mean 
in the direction from the tip of the patient's nose to his right 
ear and vice versa. 

When a patient is thus rotated — let us say toward the right — 
there is developed a nystagmus (primary nystagmus) in the di- 
rection in which he is turned; namelv, toward the right. When 



464 PHYSICAL DIAGNOSIS 

the patient is suddenly stopped, a nystagmus develops in the op- 
posite direction (after-nystagmus), the average duration of which 
is about forty seconds in a normal person. While turning the pa- 
tient toward the right the quick component of the nystagmus pro- 
duced is toward the right, and vice versa. This nystagmus is in- 
creased in intensity if the eyes are voluntarily turned toward the 
quick component, and is diminished or abolished when the eyes are 
turned toward the slow component of the nystagmus. For this 
reason Barany advises the use of smoked spectacles, which ren- 
der fixation of vision in any direction impossible, while testing 
for horizontal nystagmus by rotation tests. 

The physical basis underlying this horizontal nystagmus upon 
rotation of the patient with the head erect lies in the movements 
which are generated in the endolymph of the two horizontal semi- 
circular canals. Thus, when the patient is rapidly rotated in a 
horizontal plane — let us say toward the right — the primary move- 
ment of the endolymph in the right horizontal canal is toward 
its ampulla, whereas in the left canal it is toward the small end 
of the canal, the very movements which according to the work 
of Flour ens and Ewald are calculated to produce horizontal nys- 
tagmus toward the right. When, on the other hand, the rotation 
of the patient is suddenly terminated, the endolymph by virtue 
of its momentum is displaced in the opposite direction, w T ith a 
resulting reversal in the direction of the nystagmus. 

It follows naturally that by altering the position of the head 
during rotation different canals may be brought under investiga- 
tion and the integrity of the several elements in the labyrinthine 
system can be tested by variations in the nystagmus produced. 

It is very important to compare the relative duration of the 
after-nystagmus obtained by rotation in opposite directions. As 
has been stated, the average duration of this nystagmus after ten 
turns is about forty seconds. W T hile a difference of three or five 
seconds between the records of after-nystagmus following alter- 
nate rotations to right and left has little significance, any dis- 
crepancy above this figure is evidence of vestibular impairment. 

Having determined the nature and degree of the nystagmic 
movements as influenced by the rotation tests, the pointing tests 
and standing tests should be examined just subsequent to rotation 
of the patient, the significance of the variations being recorded 
in the accompanying table. 



THE CRANIAL NERVES 



465 



TABLE SHOWING CLINICAL FACTS UPON WHICH EQUILIBRIUM TESTS ARE BASED* 





Iw Labyrinthine 
Disease 


In Cerebellar \ Normal Individua l 
Disease 


a 

ft 

ft 


Falls J Toward the affected 
ear. 
I Direction can be 
changed by rotat- 
ing head on 
shoulders. 


Either way; most 
often toward the 
side of lesion. 


Does not fall. 




Nystagmus 


Jerky toward side 
opposite to that 
of the lesion. 


Steady; hard to 
determine direc- 
t i o n; most 
marked away 
from the side of 
the lesion. 


No nystagmus. 


X 

w 

o 

V 
Id 




Points 


Towards the side 
of the lesion with 
either hand. 


Toward the side of 
lesion with hand 
on that side; 
may point nor- 
mally with other 
hand. 


Points normally. 




c 

'35 
u 

u 

J3 
O 

12 

CO 

U 

rC 
C 

O 


Falls 


Toward the affected 
internal ear no 
matter how head 
is placed. 


•Any way ; most 
likely toward side 
of the lesion. 


Toward the ear 
tested. 


bo 
t g 

"H. 
B 

7,?, 


Nystagmus 


Jerky away from 
the side of the 
lesion. 


Steady; most 
marked away 
from side of the 
lesion or may be 
jerky away from 
the side of the 
lesion. 


Away from the side 
of the ear tested, 
jerky. 


V 

« b 

*£ 

cj 
o 

*| 

i- ft 


Points 


Toward the side of 
the lesion with 
either hand. 


Points to side of 
lesion with hand 
on side of lesion; 
hand on well side 
shows no change 
or points to side 
of lesion. 


Toward the side of 
the ear tested 
with either hand. 


bo <u 


o 

<u 

'3 
o 

§••2 

U 

3v 
u 

c 
O 


Falls 


Either way; most 
likely to side of 
the lesion. 


Away from the side 
of the lesion. 


Toward the ear 
tested. 


'S o 

« 5 

v. 
U 

< 


Nystagmus 


Jerky, both direc- 
tions; most 
marked away 
from side of le- 
sion. 


Jerky toward the 
side of the le- 
sion. 


Away from the side 
of" the ear tested, 
jerky. 


Points 


Either way with 
either hand, most 
likely towards the 
side of the le- 
sion with either 
hand. 


Toward the side of 
lesion with hand 
on that side; 
away from side 
of lesion with 
other hand. 


Toward the side of 
the ear tested 
with either hand. 



'Courtesy of Dr. C. E. Shinkle. 



466 



PHYSICAL DIAGNOSIS 



TABLE SHOWING CLINICAL FACTS UPON WHICH EQUILIBRIUM TESTS ARE BASED* 

(Continued.) 







In Labyrinthine 
Disease 


In Cerebellar 
Disease 


Normal Individual 


bo 

•S 


C 

o 
'33 

1> 

.C 

O 
1) 

IS 
u 

J3 

c 
O 


Falls 


Toward the af- 
fected internal 
ear most often. 


Any way; most of- 
ten away from 
the side of le- 
sion. 


Away from the ear 
tested. 


O w 

w o 


Nystagmus 


Jerky toward side 
opposite to that 
of the lesion. 


Steady; perhaps 
jerky towards the 
side of lesion. 


Toward the side of 
the ear tested, 
jerky. 


a) 


Points 


Confused; most of- 
ten toward the 
side of lesion 
with either hand. 


Toward the side of 
lesion with hand 
on side of the le- 
sion; other hand 
does not vary or 
points away from 
lesion. 


Away from the side 
of the ear tested 
with either hand. 


J3 o 

u 

bo -a 

t-( 
u 


o 

<L> 

'to 

a o 
o'5J 

.5 D 

J3 

C 

O 


Falls 


Toward the af- 
f e c t e d internal 
ear, no matter 
how head is 
placed. 


Toward the side of 
lesion. 


Away from side of 
ear tested. 


Nystagmus 


Jerky toward side 
opposite to that 
of the lesion. 


Jerky toward the 
side opposite to 
that of the le- 
sion. 


Toward the side of 
ear tested, jerky. 


Points 


Toward the side of 
the lesion with 
either hand. 


Toward the side of 
lesion with either 
hand. 


Away from the side 
of the ear tested 
with either hand. 




ISc 

» 5 

1* 
H 

>-M 

o 

<u 

IS 
'to 

8 
<u o 

B~ 
2:5 


Falls 


Toward the side of 
the lesion. 


Toward the side of 
lesion. 


In same direction 
as that of rota- 
tion. 




Nystagmus 


Jerky away from 
side of lesion. 


Jerky away from 
the side of the 
lesion. 


Jerky in direction 
opposite to that 
of rotation. 


c 

Oh 


Points 


Toward side of le- 
sion with either 
hand. 


Toward the side of 
lesion with either 
hand. 


In same direction 
as that of rota- 
tion. 


u 

bo 

C 


Falls 


Toward the side of 
the lesion. 


Either way; most 
likely away from 
side of lesion. 


In same direction 
as that of rota- 
tion. 




Nystagmus 


Jerky away from 
the side of the 
lesion. 


Steady or perhaps 
jerky; if the lat- 
ter, direction is 
toward the side 
of lesion. 


Jerky in direction 
opposite to that 
of rotation. 




Points 


Towards the side 
of the lesion with 
either hand. 


Toward the lesion 
with hand on 
side of lesion; 
away from lesion 
with other hand, 
if any change at 
all. 1 


In same direction 
as that of rota- 
tion. 



'Courtesy of Dr. C. E. Shinkle. 



THE CRANIAL NERVES 467 

THE GLOSSOPHARYNGEAL NERVE 

The glossopharyngeal nerve supplies sensory fibers to the 
mucous membrane of the pharynx and for the posterior third of 
the tongue. It is also the motor nerve of the middle constrictor 
of the pharynx and the stylo-pharyngeus. 

Paralysis of the nerve is evidenced by loss of taste sensation for 
the posterior third of the tongue and abolition of the pharyngeal 
reflex. Lesions of the nucleus of the nerve do not affect the sen- 
sation of taste owing to communications of the taste fibers with 
the trigeminal nerve. 

THE PNEUMO-GASTRIC NERVE 

The pneumo-gastric, or vagus nerve, arises from a nucleus 
beneath the floor of the fourth ventricle along with the nucleus 
of origin of the glosso-pharyngeal nerve. The nerve has a very 
extensive distribution, supplying motor fibers to the palate, 
pharynx, and larynx. It also sends fibers to the esophagus, 
stomach, heart, lungs, and through the sympathetic system to 
the intestines and spleen. 

Paralysis of the pneumo-gastric nerve produces uni-lateral paral- 
ysis of the palate. 'This paralysis is demonstrated by observing 
the excursion of the palate while the patient pronounces a syl- 
lable, such as the word "Ah," when only half of the palate 
rises in the normal manner. In a patient with palatal paralysis 
fluids which are ingested have a tendency to regurgitate through 
the nose. The speech is impaired, assuming a nasal quality, ow- 
ing to impairment of the innervation of the vocal cords. In uni- 
lateral recurrent laryngeal paralysis phonation is impaired but 
not abolished; but in bi-lateral recurrent laryngeal paralysis 
phonation becomes impossible. 

THE SPINAL ACCESSORY NERVE 

The spinal accessory nerve consists of two divisions: (1) the 
spinal, which arises from the anterior horns of the cervical cord 
as low as the fifth cervical nerve; and (2) the accessory, which 
arises from a nucleus situated near that for the pneumo-gastric 
nerve. The fibers of the spinal division of the nerve are dis- 
tributed to the sternomastoid and trapezius muscles, while the 



468 PHYSICAL DIAGNOSIS 

fibers arising from the accessory nucleus are distributed to the 
pharyngeal and superior laryngeal nerves. 

In testing the spinal portion of the nerve the patient is di- 
rected to rotate the head and to shrug the shoulders. In paraly- 
sis of this division of the nerve paralysis of the sterno-mastoid on 
the corresponding side causes difficulty in turning the head 
toward the sound side. Paralysis of the trapezius muscle is re- 
vealed by inability to shrug the shoulder. 

THE HYPOGLOSSAL NERVE 

The hypoglossal nerve takes origin from a center in the lower 
portion of the floor of the fourth ventricle. The nerve trunk 
emerges in a series of fascicles in the interval between the an- 
terior pyramid and the olivary body. 

The hypoglossal nerve supplies motor fibers to the tongue and 
sends motor fibers to all the muscles attached to the hyoid bone 
with the exception of the digastric, middle constrictor of the 
pharynx, mylohyoid and stylohyoid. 

Uni-lateral hypoglossal paralysis is demonstrated by direct- 
ing the patient to protrude the tongue, when it will be ob- 
served to deviate toward the paralyzed side. There is or is not 
atrophy depending on whether the lesion causing the paralysis is 
supranuclear or infranuclear. 

In bi-lateral hypoglossal paraylsis the patient is unable to pro- 
trude the tongue. 



APPENDIX 



CASE HISTORY 



Case Number Date. 



PERSONAL DATA 

Name Address 

Sex Age 

Occupation Nativity 

Civil state Number of children. 

Pathologic labors Miscarriages 



FAMILY HISTORY 

Health of parents Age and cause of death 

Health and age of sisters _, 

Health and age of brothers 

Age and cause of death of sisters 

Age and cause of death of brothers 

Special history of tuberculosis, syphilis, epilepsy, insanity, gout, and diabetes 
in family 

PREVIOUS HISTORY 

User of tobacco, alcohol or narcotic drugs 

When and for what period Dates of treat- 
ment for same 

Venereal disease (gonorrhea and syphilis) 

Dates of treatment 

Diseases during childhood (Varicella, scarlatina, mumps, pertussis, diphtheria) 

Infectious diseases (Pneumonia, tuberculosis, diphtheria, otitis, cerebro-spinal 

meningitis, typhoid fever) 

Dates Complications 

Former attack of present complaint 

Date Mode of onset . 

Former injuries Residual deformities 

Recent loss of weight 

PRESENT ILLNESS 

Date and mode of onset Treatment 

Evolution of disease to date 

Subjective symptoms 



469 



470 PHYSICAL DIAGNOSIS 

PHYSICAL EXAMINATION 

Height ft. in. Weight 1 lbs. 

RESPIRATORY SYSTEM 

Inspection : 

Herpeslabialis State of alae nasi 

Cervical veins Contour of chest 

Clavicles Supra- and infraclavicular fossae 

Uni-lateral enlargement 

Uni-lateral retraction : 

Local bulging Local retraction 

Type of respiratory expansion (Costal or abdominal) 

Respiration sterterous, stridulous or jerky 

Dyspnea Inspiratory Expiratory 

Mixed Cyanosis : 

Cheyne-Stokes breathing Litten's Phenomenon 

Present Absent 

Expansion of thorax: General increase General 

decrease Uni-lateral increase 

Uni-lateral decrease Wavy breathing 

Palpation : 

Expansion of apices Expansion of bases 

Antero-posterior expansion 

Vocal fremitus: Normal Exaggerated 

Diminished Friction fremitus 

Ehonchal fremitus Tussile fremitus 

Suecussion fremitus Sense of resistance: Normal 

Increased Decreased 

Local tenderness Fluctuation 

Crepitation Local pulsations 

Percussion : 

Normal limits of resonance Increased resonance : 

Upward Downward Anteriorly over heart: 

Dullness or impaired resonance Sites 

Flatness Sites and dimensions 

Hyper-resonance Skodaic resonance 

Tympany Signs of cavity or excavation: Cracked-pot 

sound Wintrich change of sound Interrupted 

Wintrich change of sound Gerhardt's change of sound 

Friedreich's change of sound 

Amphoric resonance Grocco's sign 

Resistance Increased Decreased 

Auscultation : 

Breath sounds: Vesicular Increased Decreased 

Bronchial Site Increased Decreased 

Broncho-vesicular Site Amphoric Site 



CASE HISTORY 471 

Cavernous Site Puerile Sites 

Prolonged expiration Cog-wheel breathing 

Vocal resonance Increased Diminished 

Bronchophony Pectoriloquy Whispering pectoriloquy 

Aegophony Absent respiratory and voice sounds 

Sites Rales Sibillant 

Sonorous Sites Crepitant Subcrepitant 

Mucous Sites Pleural friction 

Metallic tinkle Succussion sound 

Mensuration Cyrtometry of chest 

Examination of sputum 

CIRCULATORY SYSTEM 

Inspection: 

Precordial bulging Precordial retraction 

Abnormal pulsations Cardiac impulse: Site 

Extent Force Displacement Upward 

Upward and to left to left to left and downward 

to right Absent or invisible 

Systolic retraction (Broadbent's sign) 

Overfullness of jugulars (Kussmaul's sign) Diastolic 

collapse of jugulars (Friedreich's sign) 

Tortuous cutaneous veins Systolic jugular pulsations 

Hepatic pulsation Capillary pulse 

Palpation : 
Thrills Sites Time 

Pericardial friction Valve shock 

The pulse Condition of artery Rate Rhythm 

Volume Tension Omission Intermission 

Bi-lateral symmetry Dicrotism 



Percussion : 

Cardiac borders Increase to right To left 

To left and downwards General increase 

Vascular dullness Increased to right 

Auscultation: 

Heart sounds: General accentuation General diminution 

Accentuation first sound Accentuation second 

Reduplication first sound Reduplication second sound 

Endocardial murmurs Site P.M.I 

Line of transmission Time Quality 

Intensity Pericardial friction 

Pericardial succussion Flint murmur 

Venous hum Aortic murmurs 

Examination of the blood: Hemoglobin Leukocytes: Numerical 

Differential Erythrocytes Numerical 

Parasites Polychromatophilia 

Blood pressure Systolic pressure Diastolic pressure 

Pulse pressure 



472 PHYSICAL DIAGNOSIS 

THE ABDOMEN 

Inspection : 

Distended veins Caput Medusae Diastasis. 

Visible peristalsis Tumor Pigmentation. 

Scars Umbilicus Hernia 



Palpation : 

Thickness of wall Tumor of wall Fluid wave. 

Fat wave Muscular rigidity 

Muscular spasm Tenderness Site 



SPECIAL ABDOMINAL ORGANS 

The Stomach: 

Position greater curvature Lesser curvature 

Gastrectasis Gastroptosis 

Visible peristalsis Pyloric tumor 

Hour-glass constriction Tenderness 

Succussion Transillumination 

Gastric contents: Free HC1 Combined HC1 

Lactic Acid Blood 

The Intestines : 

Tenderness Tumor Impacted feces 

Gaseous distention Visible peristalsis 

Examination of feces Parasites Ova Blood 

Color Consistence Undigested food 



The Pancreas: 

Tenderness Tumor Cyst. 

Fat indigestion Cammidge Reaction 



The Liver and G all-Bladder : 

Enlargement Diminution . 

Ptosis Tenderness Systolic pulsation 

Consistence Fluctuation 

Nodules Reidel's lobe Gall-bladder tumor 

Gall-stone crepitus Peritoneal friction 

The Spleen: 

Enlargement Diminution 

Displacement Tumor Peritoneal friction , 



The Kidney: 

Tenderness Ptosis 1st degree 

2nd degree 3rd degree Cystic Tumor. 

Urinalysis 

THE HEAD AND NECK 

The Head: 

Microcephalic Megalocephalic Rickets___ 

Hydrocephalus Cretinism Fontanelles: Depressed,. 



CASE HISTORY 473 

Bulging Sutures Craneotabes 

Condition of hair: Color General loss Localized loss 

The face: Contour Pallor Cyanosis Jaundice 

Chloasma Spasm Scars Eruptions 

The eyes: Edema of lids Exophthalmos Enophthalmos 

Strabismus Hippus Nystagmus Argyll- 
Robertson pupil Ocular mobility 

The Lips: Pallor Cyanosis Epithelioma 

Chancre Fissures Parted lips 

The teeth: Premature decay Delayed dentition 

Hutchinson teeth Sordes 

The Gums: Spongy Lead line Copper line 

Red line Epulis Gingivitis 

The Tonsils: Chronic hypertrophy Tonsillitis 

Diphtheria Vincent 's angina 

The Ear: Deformity or injury Tophi Discharge 



The Neck: 

Cervical glands Thyroid 

Tracheal tug Sternomastoids Branchial 

cysts Torticollis Retraction 

THE HANDS AND ARMS 

Nails : Pallor Cyanosis 

White spots Incurvation Capillary pulse 

Fingers: Tophi Nodes Clubbed fingers 

Enlarged joints Gangrene Manual deformities 

Tremor Wrist-drop Onychia 

Forearm: Rickets Pellagra Erythema multiforme 

Arm: Ruptured biceps Tumors Paralysis 



THE FOOT AND LOWER EXTREMITY 

Gangrene Foot-drop 

Edema Ulceration Joints. 

Babinski's reflex Knee-jerk 



THE NERVOUS SYSTEM 

Headache Vomiting 

Paralysis Choked disk Convulsions 

Disorders of sensation Disturbances of speech 

Disorders of organs of special sense 

Pain, tremor Station Gait Reflexes. 

Diagnosis 

Complications 

Prognosis 

Treatment 

Besult 

Discharged 



INDEX 



Abadie 's sign, 390 

Abdomen, anatomical landmarks, 296 
anatomy, clinical, 295 

topographical, 303 
auscultation, 329 
color, 308, 309 
contour of, 317 

in ascites, 318 

in enteroptosis, 323 

in gastroptosis, 323 

in meteor ism, 318 

in obesity, 318 

in pregnancy, 318 

normal, 317 
cutaneous flexion folds, 300 
enlargement, asymmetric, 323 

symmetric, 318 
eruptions, 308 
examination of, 295 

in dorsal posture, 308 

in knee-chest posture, 308, 341 

in standing posture, 308 
fat wave, 327 
fluctuation, 326 
fluid wave, 326 
friction, 329 
inspection, 308 
mensuration, 331 
movements, absence of, 315 

respiratory, 47 

muscular rigidity, 326 

palpation, 324 

percussion, 329 

quadrants, 307 

regions, 305 

retraction, 323 

scaphoid, 323 

scars, 308 

skin, 308 

tortuous veins, 310 
Abdominal aorta, anatomy, clinical, 
300 

aneurism, 331 
cavity, 295 

viscera, examination of, 332 
Avail, 295, 325 
Abscess, cervical, 416 

metastatic in endocarditis, 266 
of brain, 167 
of liver, 358 
of lung, 163 

diagnosis, 165 



Abscess of lung — Con'td. 

distinguished from bionchiectasis, 

166 
of the lobular pneumonia, 163 . 
pathology, 163 
physical signs, 164 
empyema, 166 
pulmonary gangrene, 166 
peri-nephric, 370 
post-pharyngeal, 407 
psoas, 436 
Absence of septa of heart, 293 
Absent respiration, 87 
Accoucheur's hand, 450 
Acromegaly, facies of, 385 

spade hand of, 422 
Acute bronchitis, 100 (See Bronchi- 
tis, acute) 
endocarditis, 264 (Sec Endocarditis, 

acute) 
fibrinous pleurisy, 169 (See Pleu- 
risy, fibrinous, acute) 
myocarditis, 282 (See Myocarditis, 

acute) 
tuberculo-pneumonic phthisis, 132 
broncho-pneumonic form, 132 
diagnosis, 133 
pathology, 132 
physical sign, 132 
pneumonic form, 132 
Addison's disease, tongue of, 405 
Adhesions, pleural, 172, 180, 182 

pericardial, 259 
Adventitious sounds, 89, 224 
Aegophony, 89 (See Egophony) 
Ague-cake, 365 
Alar thorax, 40 
Albinism, pulmonary, 157 
Allorhythniic pulse, 211 
Alveoli, pulmonary, 23 
Amblyopia, 450 
Amphoric respiration, 86 
in bronchiectasis, 105 
in phthisis, 147 
resonance, 78 
Anesthesia, 444 
Analgesia, 445 
Anasarca, 38 

Anatomy, clinical, of abdomen, 295 
of aorta, 188 
of bladder, 377 
of bronchi, 19, 20, 29 
of heart, 187 
of intestine, small, 339 



475 



476 



INDEX 



Anatomy, clinical — Cont 'd. 

of kidneys, 367 

of liver and gall-bladder, 353 

of lungs, 20, 28 

of mediastinum, 17, 18 

of pancreas, 348 

of pericardium, 189 

of pleura, 17, 27 

of pleural cavity, 17 

of pulmonary artery, 188 

of stomach, 332 

of thorax, 17 

of trachea, 19, 29 

of viscera, abdominal, 295 
thoracic, 19 
Aneurism, of aorta, abdominal, 331 

thoracic, 194, 241 
axillary artery, 213 
brachial artery, 213 
innominate artery, 213 
Angina, Ludwig's, 416 

Vincent's, 408 
Angle, cardio-hepatic of Ebstein, 215 
costal, 40 

in chronic ulcerative phthisis, 40 

in hypertrophic emphysema, 40 

in rickets, 437 
costo-vertebral, 370 
of Louis, 31, 39, 40 

as normal landmark of thorax, 31 
Angulus ludovici, 31 
Anosmia, 449 
Anthracosis, 150 
pathology, 150 
Aorta, aneurism, 194, 241, 331 
auscultation, 240 
clinical anatomy, 188 
pulsation, 194 
surface marking, 192 
Aortic arch, 189 
area, 220 

incompetence, 270 (See Aortic in- 
sufficiency) 
insufficiency, 270 

aortic second sound in, 272 

capillary pulse in, 271 

Corrigan pulse in, 272 

diagnosis, 272 

Duroziez's sign in, 272 

double murmur in > 275 

pathology, 270 

physical signs, 271 

water-hammer pulse in, 272 
roughening, 273, 275 
stenosis, 273 

button-hole deformity in, 273 

diagnosis, 275 

pathology, 273 

physical signs, 274 

pulse in, 275 

relative, 273 
value, clinical anatomy, 187 

anatomic site, 192, 220 



Ape hand, 425 

Apex beat, 199 (See Impulse, cardi- 
ac) 
absence of, 201 
displacements of, 199 
extent of, 200 
site of, 199 
strength of, 201 
Apical pneumonia, 118 
Appendix, vermiform, clinical,- anat- 
omy, 343 
palpation of, 346 
Arc, reflex, 446 
Arcus senilis, 393 
Arch, costal, 33, 296 
line of, 35 
aortic, 189 
Area, aortic, 220 

auscultatory, of valves, 219 
mitral, 220 
pulmonary, 220 - 
tricuspid, 220 
Argyll-Robertson pupil, 454 
Argyria, 389, 406 
Arm, atrophy, 430 
contracture, 429 
edema of, 428 
examination of, 428 
movements, 429 
nodes, 428 
paralysis, 428 
rigidity, 429 
spasm, 429 
tumor, 428 
Arrhythmia, 210 
cardiac, 225 
extra-systolic, 228 
heart block, 228 
intermittent, 226 
respiratory, 227 
simple, 226 
Arterial murmurs, 240 
diastolic, 240 
in aorta, 240 
in carotids, 241 
in femorals, 241 
in subclavians, 241 
systolic, 240 
pressure, estimation of, 244 
pulse, 207 

analysis of, 207 
counting, 205 
sphygmogram, 206 
variations in, 206 
technic of taking, 204 
wall, 207 
Artery, axillary, aneurism of, 213 
brachial, aneurism of, 213 
carotid, murmur of, 241 
changes in, 207 
coronary, 187 



IXDKX 



477 



Artery — ('out M. 
epigastric, deep, 301 
femoral, auscultation of, 241 

double murmur in, 241 
iliac, common, 300 

external, 300 
pulmonary, 188 

surface marking, 102 

size of, 207 

subclavian, 211 
murmur in, 241 

Ascites, contour of abdomen in. 318 
Aspiration pneumonia, 123 
Astereognosis, 446 

Asthnla, bronchial, 105 (See Bron- 
chial asthma) 

cardiac, 105 

potter's, 153 

renal, 105 
Atelectasis, 154 

acquired, 154 

compression, 154 

congenital, 154 

diagnosis, 156 

obstruction, 154 

pathology, 154 

physical signs, 154 
Athetosis, 42(5 

Atrophic emphysema, 100 (Set Em- 
physema, atrophic) 
Atrophy, of arm, 430 

of heart, 199 

of nails, 419 
Auenbrugger *s sign, 256 
Auricles of heart, 187 
Auricular fibrillation, 22!) 
Auriculo-yentricular bundle. 226 
Auscultation, 82 

immediate, 82 

mediate, 82 

object of, 82 

of abdomen, 329 

of carotids, 241 

of gall-bladder, 362 

of intestine, small, 342 

of jugulars, 241 

of liver. 362 

of lungs and bronchi. 82 

of precordia, 219 

of stomach, 339 

of subclavians, 241 
Auscultatory valve areas, 219 

percussion, 68 
of stomach, 338 
Axillary line, anterior, 34 
posterior, 34 

region, 35 



B 



Babinski 's sign, 447 



Baccelli 'g sign — Cont 'd, 

in sero-fibrinous pleurisy, 175 
Back, percussion of, 70 
Barany tests, 460 
Barrel chest, in 
Bell tympany, 81 
Belt sign, Glenard's, 
Biermer's phenomenon, 80 
Bladder, clinical anatomy of, .",77 

examination of, 377 
Blepharitis marginalia, 392 
Blepharospasm, 390 
Blood pressure, arterial, 242 

definition, 242 

diastolic, 251 

estimation of, 244 

ausculatory method, 249 
palpatory method, 248 

normal variations, 250 

pathologic variations, 250 

phases, 249 

systolic, 244, 250 
diminished, 250 
increase. 1, 250 

venous, 251 

Oliver's method <o' estimation 
of, 252 
Bones, cranial, 380, 381 
bosses, 381 
craniotabes, 381 

swelling. 381 
tenderness. 381 
Borborygmus, 342 
Bradycardia, 210, 227 

Stokes-Adams, 22s 
Branchial cyst, 41(5 

fistula, 410 
lb-east, funnel, 40 
keel, 44 
pigeon, 44 
Breath, acetone. t00 
foul, 400 
uremic, 400 
Breathing, 83 (See Respiration) 
Bronchi, clinical anatomy. 19, 22 
diseases of, 100 
stenosis, 108 
surface markings. 29 
Bronchial asthma, 105 

Charcot-Leyden's crystals in, 107 
Curschmann 's spirals in, 107 
diagnosis, 107 
eosinophils in, 106 
pathology, 105 
physical signs. 107 
rales in, 107 
Bronchiectasis, 103 
cylindric, 103 
diagnosis of, 105 
pathology of, 103 
physical signs, 104 
saccular, 103 



478 



INDEX 



Bronehiectatic cavities, 103 
pectoriloquy in, 89 
tympany in, 78 
Bronchiole, clinical anatomy of, 22 

terminal, 22 
Bronchitis, acute, 100 
diagnosis, 101 

distinguished from, broncho-pneu- 
monia, 101 
lobar pneumonia, 101 
pertussis, 102 
chronic, 102 
diagnosis, 102 
pathology, 102 
physical signs, 102 
putrid, 102 
Broncho-pneumonia, 123 
diagnosis, 127 

distinguished from, acute bronchi- 
tis, 101, 127 
lobar pneumonia, 122, 127 
meningitis, 128 
phthisis, 128 
pathology, 123 
physical signs, 125 
Broncho-pneumonic phthisis, acute, 

132 
Bronchorrhoea serosa, 102 
Broncho-stenosis, 108 (See Tracheo- 
bronchial stenosis) 
Broncho-vesicular respiration, 87 
Broadbent's sign, 198 
Bruit de diable, 241 
de drapeau, 90 
de galop, 224 

in chronic adhesive pericarditis, 260 
Buccal cavity examination of, 406 
Bulging, local, of thorax, 47 

uni-lateral, of thorax, 46 
Bundle, auriculo-ventricular of His, 

226 
Button-hole mitral defect, 278 



Calves, swelling, 432 
Cancrum oris, 400 
Canities, 382 
Canter-rhythm, 224, 292 
Capillaries, pulmonary, 23 
Capillary pulse, 201, 417 

in aortic insufficiency, 271 
Caput medusae, 38 
Cardiac, (See Heart) 

impulse, 199 (See Impulse, cardiac) 
Cardio-hepatic angle, 215 

dullness of, 257 
Carotid artery, examination of, 241 

murmur in, 241 

pulsation, 287 
Catarrh Sec of Laennec, 102 
Catarrhal pneumonia, 123 (See Bron- 
cho-pneumonia") 



Cavernous respiration, 86 

in phthisis, 147 
Cavity, buccal, 406 
color, 406 
dryness, 406 
eruptions, 406 
moisture, 406 
mucous patch, 406 
noma, 406 

bronehiectatic, 78, 103 
pleural, 17 

pulmonary, 79, 80, 89 
tuberculous, 137 
Cecum, clinical anatomy, 343 

examination of, 345 
Cells, heart-failure, 110 
mastoid, inflammation, 381 
Purkinje, 226 
Central pneumonia, 118 
Centripetal venous pulse, 198 
Cervical glands, enlargement, 412 
veins, diastolic collapse, 260 
overfullness, 260 
Chalazion, 392 
Chalicosis, 150 
Chalk-stones, 421 
Charcot -Leyden crystals, 107 
Charcot's joint, 433 
Chest, clinical anatomy, 17 (See 
Thorax) 
landmarks of, 29 
Cheyne-Stokes respiration, 52 
Chloasma, 309, 389 
Cholecystitis, point of tenderness, 358 
Cholelithiasis, point of tenderness, 358 
Chordae tenderness, shortening, 267 
Chorea, gravidarum, 429 
hemiparalytic, 429 
Sydenham's, 383 
Chronic adhesive pericarditis, 259 (See 
pericarditis, chronic, adhe- 
sive) 
endocarditis, 267 

interstitial pneumonia, 129 ( See 
Interstitial pneumonia, ehron- 
ie) 
myocarditis, 284 (See Myocarditis 

chronic) 
ulcerative phthisis, 133 
cavities in, 141 
diagnosis, 143 

distinguished from bronchiectasis, 
144 
lobar pneumonia, 144 
malaria, 144 
pulmonary abscess, 144 
pulmonary gangrene, 144 
hemoptysis in, 141 
Lorenz's sign, 138 
pathology, 133 
physical sign, 138 
pneumothorax in, 137 
pulse in, 142 



INDEX 



479 



Chronic ulcerative phthisis — Cont M. 
Rothschild's sign, 138 
thorax of, 38, 40, 138 

valvular disease, 268 
Chylothorax, 183 

pathology, 183 

physical signs, 183 
Circulatory organs, clinical anatomy 
of, 187 

examination of, 187 
Cirrhosis of lung, 47, 129 (See Chronic 
interstitial pneumonia) 

after lobar pneumonia, 129 
Claudication, intermittent, 436 
Clavicles, as normal landmarks, 31 

prominence of, 32, 40 
Clavicular line, 35 
Click, mucous, 143 
Clonus, ankle, 447 

patellar, 447 
Clubbed fingers, 418, 422 
Coal miner's disease, 150 
Cog-wheel respiration, 87 
Coin test, Gairdner's, 81 
Collapse, diastolic, of jugulars, 196 

pulmonary, 46, 155 
Colon, ascending, 343 

clinical anatomy, 343 

descending, 345 

palpation of, 345 

transverse, 343 
Color changes in skin of abdomen, 

308, 309 
Color-blindness, 450 
Compensation of heart, 269 

broken, 269 
Compensatory emphysema, 46, 161 
(See Emphysema compensa- 
tory) 
Complementary sinus, 28 
Congenital heart disease, 293 (Sec 

Heart disease, congenital) 
Congestion, active, 110 

collateral, 110 

diagnosis, 111 

hypostatic, 110 

mechanical, 110 

passive, 110 

pathology, 110 

physical signs, 111 

pulmonary, 110 
Conjunctiva, cyanosis, 392 

examination of, 392 

hemorrhage, 392 

pallor, 392 

yellowness, 392 
Conjunctivitis, 392 
Contour, abdominal, 317 
Contracture, Dupuytren's, 425 

of arm, 429 
Contraction, local, of thorax, 47 

uni-lateral, of thorax, 46 
Convulsive tic, 390 



Cook's sphygmomanometer, 243 
Cor biloculare, 293 

bovinum, 271, 287 

triloculare, 293 

villosum, 254 

< lornea, opacity, 394 

ulceration, 394 
Corrigan button-hole orifice, 27:; 
Corrigan's disease, 270 
Corset liver, 358 
Costal angle, 40 
arch, 33, 296 
line of, 35 
line, sixth, '■'>'> 

third, 35 
respiration, 47 
Costo-abdominal respiration, 47 
( losto-vertebral angle, 370 
( lough of aortic aneurism, 103 

of pulmonary edema, 112 
( !racked-pot sound, 78 

in bronchiectasis, 105 
in phthisis, 142 
in sero-fibrinous pleurisy. 171 
Cranial nerves, examination of, 448 
Craniotabes, 379, -". s l 

< Irepitant rale, 91 
Crepitation, gall-stone, 362 
Crepitus, 63, 163 

( 'retinisin, fades of, 380 
head of, 380 

< Irico-clavicular line, 34 

Croupous pneumonia, lib" {Set Lobai 

pneumonia) 
Curschmann's spirals, 107 

Curve. Kllis'. 170 

Cyanosis ^2, 389, 396, 406, 417 

Cycle, cardiac, 225 

Cyrtometer, ;>t 

Cyrtometry, 94 

Cyst, blood, W5 

branchial, 416 

echinococcus, 405 

lingual, 405 

Meibomian, 392 

mucous, 405 

of auricle, 384 

respiratory, 47 
Cysticercua cellulosae, 405 

D 

Dactylitis, 422 
Day-blindness, 450 
Deafness, nerve. 459 

middle ear, 459 
Decubitus, in lobar pneumonia, 118 

in sero-fibrinous pleurisy. 173 
Degeneration, myocardial, acute, 282 
Deglutition pneumonia, 123 
Delirium cordis, 229 
Dentition, delayed, 400 

premature, 400 



480 



INDEX 



Diaphragm movements, 49, 50 
Diaphragmatic phenomenon, 49 

pleurisy, 177 
Diastole, auricular, 196 
Diastolic collapse, jugular, 196 
murmurs, 231 
aortic, 234 
pulmonary, 237 
pressure, 244 
Dicrotic notch, 206 
pulse, 212 
wave, 206 
Dilatation, auricular, left, 290 
right, 290 
bronchial, 103 
cardiac, 289 
diagnosis, 292 

distinguished from encysted 
pleurisy, 292 
sero-fibrinous pericarditis, 258 
pathology, 289 
physical signs, 291 
pulse in, 291 
ventricular left, 290 
right, 290 
Diplegia, 443 
Disease, Addison's, 405 
Banti's, 358, 364 
Corrigan's, 270 
Hodgkin's, 414 
• Little 's, 437 
Morvan's, 422 
Paget 's, 436 
Pott 's, 416 
Baynaud's, 422 
Thompson's, 402 
"Weil's, 358 
Woillez's, 123 
Dittrich's plugs, 102 
Double murmur of Duroziez, 272 

pneumonia, 118 
Dry rales, 90 
Dullness, 74 
at apices, 74 
at bases, 76 
cardiac, area of, 214 
displacement, 216- 
general decrease, 216 
general increase, 216 
increase to left, 216 
increase to right, 216 
upward increase, 216 
hepatic, 359 

in broncho-pneumonia, 126 
in cardio-hepatic angle, 257 
in chronic bronchitis, 102 
in chronic interstitial pneumonia, 

131 
in chronic ulcerative phthisis, 142 
in lobar pneumonia, 119 
in pulmonary edema, 112 
in sero-fibrinous pleurisy, 174 
movable, 174 



Dullness — Cont 'd. 

of lung, 74 

over mammae, 70 

over scapulae, 70 

over Traube's semilunar space, 174 

para-vertebral, 76, 174 

sternal, 70 

uni-lateral, 74 

vascular, 218 
Duodenojejunal flexure, 339 
Duodenum, clinical anatomy, 339 
Dupuytren's contracture, 425 
Duration, of percussion sound, 69 

of pulse, 212 
Duroziez 's sign, 272 

in aortic insufficiency, 272 
Dyspnea anemic, 52 

cardiac, 52 

expiratory, 52 

hemic, 53 

in acute bronchitis, 100 

in atelectasis, 155 

in bronchial asthma, 107 

in broncho-pneumonia, 125 

in chronic adhesive pleurisy, 182 

in chronic bronchitis, 102 

in emphysema, hypertrophic, 158 

in phthisis, 138 

in pulmonary congestion, 111 
edema, 112 

in sero-fibrinous pericarditis, 256 



E 



Ear, congenital defects, 383 
cyanosis, 384 
cysts, 384 

discharge from, 384 
examination of, 383 
hematoma, 384 
keloid, 384 
otomycosis, 384 
tophi, 384 
Ebstein's cardio-hepatic angle, 215 
Echinococcus cyst of liver, 358 
Edema of lungs, 111 
diagnosis, 112 
pathology, 111 
physical signs, 112 
of eyelids, 391 

dullness of, 257 
of thorax, general, 38 
local, 38, 54, 181 
Effects of valvular lesions, 269 
Egophony, 89 

in sero-fibrinous pleurisy, 175 
Elbow, miner's, 430 
Ellis' curve in sero-fibrinous pleurisy, 

176 
Embolic abscess of lung, 164 

gangrene of lung, 166 
Embryocardia, 228, 284 
Emphysema, acute vesicular, 162 



[NDEX 



481 



Emphysema, acute vesicular — Conl M 
pal bology, 102 
physical signs, 163 
atrophic, 160 
diagnosis, 161 
palhology, 160 
physical signs, 160 
chronic, 156 
compensatory, 161 
diagnosis, 162 
pathology, 161 
physical signs, KM 
diffuse, L56 
hypertrophic, 156 
diagnosis, 159 

distinguished from chronic bron- 
chitis, 159 
from sero -fibrinous pleurisy, 

159 
from pneumothorax, 159 
Freund's theory of, 156 
pathology, 156 
physical signs, 158 
thorax of, 40, 158 
idiopathic, 156 
interstitial, L62 
pathology, 162 
physical signs, 163 
large-lunged, of Jenner, 156 
pulmonary, 156 
substantive, 156 
Emphysematous crackling, 163 
Empyema, 179 
diagnosis, 182 
local edema in, 38, L81 
necessitatis, 38, 181 
pathology, 179 
physical signs, 18] 
pulsating, L81 
Endocardial murmurs, 229 (See Mur- 
murs, endocardial) 
Endocarditis, acute, 264 
diagnosis, 266 
distinguished from typhoid fever, 

267 
pathology, 264 
physical signs, 266 
chronic, 267 
infective, 2<i5 
malignant, 265 
mural, 264 
pathology, 267 
recurrent, 204 
simple, 264 
valvular, 264 
Enophthalmos, 393 
Ensiform cartilage, 33, 44, 296 
Enterolith, 340 
Enteroptosis, 323 

abdominal contour in, 323 
Epicardium, 188 



Epigastric artery, deep, surface mark- 
ing, 301 

region, 305 
Epigastrium, bulging, 363 

pulsation in, 271, 276 

retraction of, 125, 155 
Epilepsy, Jacksonian, 443 
Epithelioma, of eyelid, 392 

of lip, 398 
Epithelium, respiratory, 22 
Epistaxis, 395 
Epulis, 401 

Erlanger's sphygmomanometer, 244 
Erythema nodosum, 428 
Erythromelalgia, l-".2 
Ewart 's sign, 257 
Excrescences of cardiac valves, 265 

verrucose, 265 
Excursion, inspiratory, of tie. rax. 47 
Exophthalmos, 392 
Expansion, wavy, 54 
Exudate in acute fibrinous pericar- 
ditis, 253 

in plastic pleurisy, 169 
Eyelid, chancre, 392 

duskiness. 391 

edema. 391 

epithelioma, 392 
ptosis, 391, 456 
Eyes, conjugate deviation of, 155 
examination of, 391 



r 



Face, blush discoloration, 389 
brown patches, 389 
color, 3S9 

contour of, 385 

in acromegaly, .". s "» 

in cretinism. $85 

in hydrocephalus, 385 

in leontiasis ossea, " ss 
in leprosy, 388 
in myxedema, 385 

in osteitis deformans, 385 

cyanosis, "'M' 

examination of, 385 

flushing, 389 

pallor, 389 

spasm. 390 

yellowish discoloration. 389 
Facies emphysematous, 158 
Falciform ligament. 353 
Falling drop sound, 90, 91 
Fat wave. 327 

Faughts ' sphygmomanometer, 246 
Femoral artery, double murmur in, 

241 
Fetus, pneumonia alba of, 148 
Fibrillation, auricular, 229 
Fibrinous pericarditis, acute. 253 



pleurisy, acute, 169 



482 



INDEX 



Fibroid phthisis, 144 
diagnosis, 148 
pathology, 144 
physical signs, 145 
Finger percussion, 65 
Fingers, clubbed, 418, 422 
distortions, 422 
enlarged joints, 421 
Heberden's nodes, 421 
Hippocratic, 422 
Morvan's disease, 422 
Raynaud 's disease, 422 
tophi, 419 
Fistula, branchial, 416 
Fistula sound, lung, 90, 93 
Flat-foot, 431 
Flatness, 76 

cardiac, area of, 214 
hepatic, area of, 259 
Flexion folds of abdomen, 300 
Flexure duodeno-jejunal, 339 

sigmoid, 345 
Flint murmur, 232, 272, 279 
Floating kidney, 373 
Fluctuation, abdominal, 326 

in thoracic disease, 64 
Fluid veins, 203; 229, 240 

wave, 326 
Fluoroscope, 95 
Fluoroscopy, 95 
Fontanelles, 380 
bulging, 380 
depression, 380 
enlargement, 380 
tardy closure, 380 
Foot, club, 432 
enlargement, 432 
examination of, 431 
flat, 431 
Foramen ovale, patent, 293 
Force of percussion, 68 

pulse, 211 
Forearm, edema, 428 

epiphyseal enlargement, 428 
erythema nodosum, 428 
examination of, 428 
Forehead, eruptions, 3yl 

examination of, 391 
Fossa infra-clavicular, 39 

supra-clavicular, 39 
Fremitus, friction, pericardial, 202 
peritoneal, 329 
pleural, 63, 93 
rhonchal, 63 
succussion, 63 
tussile, 63 
vocal, 58 
absent, 62 
decreased, 62 
increased, 62 
normal variations, 58 



Friction, abdominal, 331 

fremitus, pleural, 17, 63, 93, 173, 
183 
pericardial, 329 
pleuro-pericardial, 175, 256 
perihepatitic, 331 
perisplenic, 331 
Friedreich's sign, 196 

in chronic adhesive pericarditis, 
260 
respiratory change of sound, 80, 
105 
Functional murmurs, 238 (See Mur- 
murs, functional) 
Funnel chest, 46 

G 

Gairdner's coin test, 81 
Gait, 440 
ataxic, 441. 
cerebellar, 442 
festinating, 442 
hemiplegic, 440 
spastic, 440 
steppage, 441 
vertiginous, 442 
Gall-bladder, clinical anatomy, 353 
crepitations, 362 
examination of, 353 
inspection of, 355 
palpation of, 358 
surface marking, 358 
Gallop-rhythm, 224, 284, 292 
Gall-stone crepitation, 362 
Ganglion, 425 
Gangrene of lung, 166 

after lobar pneumonia, 166 
circumscribed, 166 
diagnosis, 167 
diffuse, 166 

distinguished from pulmonary 
abscess, 167 

pulmonary tuberculosis, 1 08 
pathology, 166 
physical signs, 167 
Gastrectasis, 333 
Gastroptosis, 335 

abdominal contour in, 323 
Geographical tongue, 404 
Gerhardt's change of sound, 80 
in bronchiectasis, 105 
in chronic ulcerative phthisis, 
142 
Gladiolus, 31 

Gland, Blandin-Nuhn 's, 405 
mammary, 32, 38, 39 

as landmark of thorax, 32 
hypertrophy of, 39 
thyroid, 411 
Glands, enlarged, inguinal, 314 
cervical, 412, 413, 414 
epitrochlear, 419 
occipital, 413 



INDEX 



483 



Glands, enlarged — Cont 'd 

parotid, 413 
submaxillary, 413 
supra-clavicular, 414 
Glandular enlargement, .'514, 412 
Glenard 's belt sign, 338 
Globe, of eye, 392 

position of, 393 
Goiter, cystic, 411 

exophthalmic, 412 
Gout, toe of, 431 

tophi of, 419 
Grinder's rot, 153 
Grocco 's sign, 70 

in purulent pleurisy, 181 

in sero-fibrinous pleurisy, 174 
Groove, Earrison 's, 44 
Gummata, pulmonary, 148 
Gums, blue line, 401 

examination of, 401 

in diabetes, 401 

in gingivitis, 401 

in mercurial poisoning, 401 

in pellagra, 401 

in pyorrhea alveolaris, 401 

in scorbutus, 401 

in ulcerative stomatitis, 401 

red line, 401 

sponginess, 401 

tumor, 401 
Gurgling, in hour-glass stomach, 339 

rales, 91 
Gutta cadens, 185 

11 

Hair, color, 381 

crepitus, 83 

falling, circumscribed, 381 
general, 381 
Hand, accoucheur's, 425 

ape, 425 

claw, 424 

examination of, 417 

hemiplegic, 424 

seal-fin, 425 

shape, 422 

spade, 422 

tremor of, 425 
Harelip, 400 
Harrison 's sulcus, 44 
Haygarth's nodosities, 4L'l 
Head bones, 380 

cretinoid, 380 

deviation, lateral, 382 

examination, 379 

fixation, 383 

fontanelles, 380 

hydro-cephalic, 380 

movements, 383 

position, 382 

rachitic, 379 

retraction, 382 

shape, 379 



Bead — Cont '<l 

size, 379 
sutures, 380 
Heart, apex of, 187 

displacement, 199 

site, 199 

thrill at, 204 
arrythmia, 225 
atrophy, 199 
auricles, 187 
automaticitv, 225 
base, 187, 190 

pulsation at, 194 

thrill at, 204 
beat, myogenic, 220 

neurogenic, 220 
block, arrythmia, 228 
borders, 187, 191 
conductivity, 225 
cycle, 22."> 

dilatation, 289 (See Dilatation, car- 
diac i 
disease, congenital, 293 
diagnosis, 294 
pathology, 293 
physical signs, 294 
dullness, area of, 21 4 

decreased, 216 

displaced, 216 

increased, 210 

extra -systole of, 228 

failure cells, 110 

flatness, area of. 214 

hypertrophy, 285 (Sa Hypertrophy 

cardiac) 
impulse, 199 (See Impulse cardiac) 
irritability, 225 
orifices, 187 
palpation, 202 
palpitation, 227 
rhythmicity. 225 
sounds, 210 

accentuation of, 221 
adventitious, 224 
diminution of, 221 
equalization of. 283 
fetal, 331 
first, 219 

accentuation of, 222 

enfeeblement of, 222 

reduplication of, 223 

in acute myocarditis, 283 

in aortic insufficiency, 272 

stenosis. 275 
in cardiac dilatation, 292 

hypertrophy, 287 
in chronic adhesive pericarditis. 
260 
myocarditis, 285 
in lobar pneumonia, 120 
in mitral insufficiency, 277 

stenosis, 279 
in pulmonary insufficiency, 279 



484 



INDEX 



Heart sounds — Cont'd 

in pulmonary stenosis, 280 
in tricuspid insufficiency, 281 
intensity of, 222 
reduplication of, 222 
second, 219 

accentuation of, 222 
enfeeblement of, 222 
reduplication of, 223 

surface marking, 190 

valves, 187, 192 
Heberden's nodes, 421 
Hemeralopia, 450 
Hemianopia, 452 
Hemiatrophy, facial, 388 
Hemicliorea, 443 
Hemi-hypertrophy, facial, 389 
Hemiplegia, 443 
Hemo-pericardium, 261 

pathology, 261 

physical signs, 261 
Hemoptysis, in phthisis, 141 

in pulmonary syphilis, 150 
Hemorrhage in phthisis, 136 
Hemorrhagic infarction of lung, 112 
Hemothorax, 183 

pathology, 183 

physical signs, 183 
Hepatization, gray of lung, 117 

red of lung, 117 
Hepatoptosis, 361 
Hernia, femoral, 436 

umbilical, 313, 323 
Herpes, labialis, 397 

in lobar pneumonia, 118 
Hippocratic fingers, 422 

succussion sound, 92 
Hippus, 454 
Hissing respiration, 51 
Holmgren test, 450 
Hordeolum, 392 
Hour-glass stomach, 339 
Housemaid's knee, 435 
Hum, venous, 241 
Humming-top murmur, 241 
Hutchinson's teeth, 401 
Hydrocephalus, facies of, 385 
Hydro-nephrosis, fluctuation in, 373 
Hydro-pericardium, 261 

pathology, 261 

physical signs, 261 
Hydro-pneumothorax, 184 (See Pneu- 
mothorax) 
Hydrops, pericardii, 261 
Hydrothorax, 184 

distinguished from sero-fibrinous 
pleurisy, 176 

pathology, 184 

physical signs, 184 
Hypalgesia, 445 
Hyperalgesia, 445 
Hyperesthesia, 444 



Hyperosmia, 449 

Hyper-resonance, in compensatory em- 
physema, 77, 162 
in hypertrophic emphysema, 77, 158 
local, 77 
pulmonary, 76 
relaxation as cause, 77 
Hypertrophic emphysema, 40, 156 (See 

Emphysema, hypertrophic) 
Hypertrophy, auricular left, 288 
right, 288 
cardiac, 285 
concentric, 285 
cor bovinum in, 287 
diagnosis, 289 

distinguished from cardiac dilata- 
tion, 289 
from sero-fibrinous pericarditis, 
289 
eccentric, 274, 285 
general, 287 
physical signs, 287 
prostatic, vesical distention in, 377 
pulse in, 287 
ventricular left, 287 
right, 287 
Hypesthesia, 444 
Hypochondriac region, 35 
Hypogastric region, 306 
enlargement, 323 



Ileo-cecal valve, clinical anatomy, 339 
Ileum, clinical anatomy, 339 
Iliac artery, common, 300 
external, 300 
region, 307 

spine, anterior superior, 297 
Illumination, direct, 38 

oblique, 38 
Immediate auscultation, 82 

percussion, 65 
Impaired resonance, 74 
Impulse, cardiac, 199 
absence, 201 

displacement, downward, 199 
to left, 200 
to right, 200 
upward, 199 
extent. 200 
site of, 199 

in child, 199 
strength, 201 
Infarction, hemorrhagic, of lungs, 112 

of spleen, 365 
Infective endocarditis, 265 (See Endo- 
carditis, acute) 
Infiltration, purulent, of lung, 164 
Infra-axillary region, 35 
Infra-clavicular region, 35 
Infra-scapular line, 35 

region, 307 
Infundibulum, 22 



INDEX 



485 



Inguinal glands, enlarged, 314, 436 

region, 307 
[nnominate artery, aneurism of, 213 
I nspection, 37 
of abdomen, 308 
of bladder, 377 
of gall-bladder, 355 
of intestine, large, 343 

small, 340 
of kidneys, 370 
of liver, 355 
of precordia, 194 
of spleen, 363 
of stomach, 333 
of thorax, 37 
Instrumental estimation of blood pres- 
sure, 244 
percussion, 35 
Insufficiency, aortic, 270 (See Aortic 
insufficiency) 
mitral, 276 (See Mitral insuffi- 
ciency) 
pulmonary, 279 (See Pulmonary in- 
sufficiency) 
tricuspid, 280 (See Tricuspid in- 
sufficiency) 
relative, 280 
Intensity of murmurs, 231 
of percussion sounds, 69 
Intention, tremor, 425 
Intercostal spaces as landmarks of 
thorax, 32 
bulging, 182 
narrowing, 46, 146, 160 
retraction, 40, 51, 145, 155 
widening, 40 
Intermission, 210 
Intermittence, 226 
Intermittent claudication, 436 
Inter-scapular region, 36 
Interstitial myocarditis, 282, 284 
pneumonia, chronic, 129 
circumscribed, 129 
diagnosis, 131 
diffuse, 129 
pathology, 129 
physical signs, 130 
Intra-ventricular septum, defects of, 

293 
Intestinal obstruction, 314 

visible peristalsis in, 314 
Intestine, large, clinical anatomy, 343 
examination of, 343 
small, clinical anatomy, 339 
examination of, 339 



Janeway 's sphygmomanometer, 245 
Jejunum, clinical anatomy, 339 
Joint, Charcot's, 433 
Joints, enlarged, of fingers, 421 



Jugular veins, auscultation, 241 
diastolic collapse, 196 
engorgement, 260 
murmur in, 241 
systolic pulsation in, 196, 280 

K 

Keel breast, 44 
in rickets, 45 

in tonsillar hypertrophy, 45 
Keloid, 384 

Keratitis, interstitial, 393 
Kernig's sign, 433 
Kidneys, clinical anatomy, 367 
displaced, 373 
enlarged, 37:; 
examination of, 367 
floating, 373 
movable, 373 

degrees of, 373 
palpation of, 370 
polycystic, 37-1 
tumor of, 37.1 

distinguished from enlarged gall- 
bladder, 375 
distinguished from enlarged 

spleen, 375 
distinguished from pyloric tumor, 
375 
wandering, 373 
Knee, housemaid's, L">.~> 

jerk, 446 
Kyphosis, 44 



Laennec's Catarrh Sec, 102 
Lagophthalmos, 392 

Laryngeal stenosis, breathing in, 51, 
411 

Larynx, deflection of, 409 

prominence of, 40 
Legs, atrophy, 432 

1 towing, 432 

examination of, 432 

nodes, 432 

ulcus, 432 

varicose veins, 432 
Leontiasis ossium, facies of, 388 
Leprosy, facies in, 388 
Leukoplakia, 404 
Ligament falciform, 353 

Poupart's, 297 
Ligamentum arteriosum, 189 

latum pulmonis, 20 
Ligneous phlegmon, 416 
Line, axillary anterior, 34 
posterior, 34 

clavicular, 35 

costal, sixth, 35 
third, 35 

crico-clavicular, 34 

infra-scapular, 35 



486 



INDEX 



Line — Cont 'd. 

intertubereular, 304 
mammary, 33 
mid-axillary, 34 
mid-clavicular, 33 
mid-poupart, 304 
mid-spinal, 34 
mid-sternal, 33 
nipple, 33 

of transmission of murmurs, 231 
scapular, 34 
spinal, 35 
• sternal, 33 
sub-costal, 304 
twelfth dorsal, 35 
Linea alba, 298 
nigra, 298 
semilunaris, 298 
Lineae albicantes, 308 

transversa}, 299 
Lips, chancre, 397 
cyanosis, 396 
enlargement, 397 
epithelioma, 398 
fissures, 397 
herpes, 397 
mucous patch, 397 
pallor, 396 
partid, 397 

pendularis, lower, 397 
rhagades, 397 
Litten's phenomenon, 43 

absence of, 50 
Liver areas of dullness and flatness, 
359 
auscultation of, 362 
clinical anatomy, 353 
corset, 358 

decreased size of, 361 
downward displacement, 361 
inspection of, 355 
palpation of, 357 
percussion, 359 
pulsation, 195, 237, 276, 281, 290, 

355 
Eiedel's lobe, 358 
surface marking, 354 
tumors of, 359 

distinguished from renal, 359 
upward displacement, 361 
Lobar pneumonia, 116 

abscess of lungs after, 163 
cirrhosis of lung after, 129 
distinguished from acute bronchitis, 
101 
acute pneumonic phthisis, 121 
broncho-pneumonia, 122 
pulmonary congestion, 123 
edema, 122 
infarction, 122 
sero-fibrinous pleurisy, 123 
gangrene of lungs after, 166 
heart sounds in, 120 



Lobar pneumonia — Cont 'd. 

pathology, 116 

pleurisy in, 117 

pulse in, 119 

purulent infiltration in, 163 

rale indux in, 120 
redux in, 120 

roentgenogram, 98 

sputum, 117 

stage of engorgement, 116 . 
gray hepatization, 117 
red hepatization, 117 
resolution, 163 
Lobular pneumonia, 123 (See Bron- 
cho-pneumonia) 
Lordosis, 44 
Lorenz, sign of, 138 
Louis, angle of, 31, 39, 40 
Ludwig's angina, 416 
Lumbar region, 306 
Lungs, abscess of, 157 

albinism of, 157 

auscultation of, 82 

borders, 20, 28 

bronchioles, 22 

carcinoma of, 114 (See Pulmonary 
neoplasms) 

catarrhal pneumonia, 123 

cavities, tympany in, 78 

circulation, 23 

circulatory disturbances, 110 

cirrhosis of, 129 

clinical anatomy, 20 

collapse of, 46, 155 

congestion of, 110 (See Pulmonary 
congestion) 

costal surfaces, 20 

disease of, 116 

dullness of, 74 

dyspnea, 52 

edema, 111 

emphysema, 156 

endothelioma of, 114 

fibroid retraction of, 195 

fissures of, 20, 28 

fistula sound, 90, 93 

flatness of, 76 

gangrene of, 166 

hepatization of, 117 

hilus of, 20 

infarction of, 112 (See Pulmonary 
infraction) 

infundibular of, 22 

inspection of, 37 

ligament of, 20 

lobes of, 20 

lower borders, 28 

lymphatics of, 25 

mediastinal surfaces, 20 

normal limits, 71 

palpation of, 55 

pancreatization, 148 

percussion of, 65 



INDEX 



4-7 



Lungs, percussion of — Cont'd. 
apices, 70 

auscultatory, 68 
palpatory, 68 

respiratory excursion of, 74, 170 
root of, 20 
sarcoma of, 114 

sclerosis of, 129 
surface markings, 28 
syphilis of, 148 
tumors of, 114 
tympany of, 78 
Lymph nodes, bronchial, 25 
mediastinal, 25 
pulmonary, L'5 

M 

Maerocheilia, 397 
Microglossia, 401 
Main-en-griffe, 424 

Malignant endocarditis, 12* >-"> 
diagnosis, 2 HO 
physical signs, 266 
Mai perforante, 431 
Mammary gland, 32, 38, 39 
as landmark of thorax, 32 
hypertrophy of, 39 
line', 33 
region, 3.5 
Manubrium stemi, 31 
McRurney's point, 346 
Med in stiu (i- pericarditis, 2.59 
Mediastinum, anterior, 19 
contents of, 19 
middle, 18 

contents of, 18 
posterior, 18 

contents of, 18 
superior, 18 

contents of, 18 
tumors of, 19 
Mediate auscultation, 82 
percussion, 65 

rules governing, 65 
Megalonychosis, 419 
Mensuration of abdomen, 331 

thorax, 94 
Metallic tinkle, 89, 01 
Meteorism, abdominal contour in, 318 
Mid-axillary line, 34 
Mid-clavicular line, 33 
Mid-poupart line, 304 
Mid-spinal line, 34 
Mid-sternal line, 33 
Mill-stone maker 's phthisis, 153 
Miner 's elbow, 430 
Mitral area, 220 
insufficiency. 27d 
diagnosis, 277 
pathology, 270 
physical signs. 270 
pulmonary second sound in, 277 
pulse in, 277 



Mitral— Cont 'd. 
murmurs, 231 

presystolic, 232 

systolic, 233 
stenosis, 277 

button-hole orifice in, 278 

diagnosis, 279 

pathology of, 277 

physical signs, 278 

pulse in, 278 

thrill in, 27S 
value, 187 
Moist rales, 90, 91 
Money-chink resonance. 78 
Morvan's disease, 422 
Movable kidney, .".7:; 
Mucous click, 14:; 

rales, 91 
Multiple murmurs, 238 
Murmurs, accidental, 238 
aortic, 234 

diastolic, 234 

systolic, 234 
arterial, 240 

diastolic, 240 

systolic, 241 
caidio-respiratory, 2.".! 1 . 287 
diastolic, 231 

double in aortic insufficiency, 23.5 
Duroziez's, 241. 272 
endocardial, 229 

characteristics of, 230 

generation of. 22!' 
flint, 232, 2 7i'. _" 
functional. 238 

relative incidence. 238 
hemic, 238 
humming top, 241 
inorganic, 238 
intensity of, 231 
line of transmission, 231 
mitral, 231 

presystolic. 232 

systolic. 233 
monplegia, 442 
multiple, 23S 

separation of. 238 
nun's, 241 
organic. 220 

point of maximum intensity. 230 
pulmonary, 237 

diastolic. 23S 

systolic, 237 
quality of, 231 
safety-valve. 27(3. 277. 279 
time of, 231 
tricuspid, 236 

presystolic, 236 

systolic, 236 
vascular, 240 
venous, 241 



488 



INDEX 



Musculature of thorax, 38, 39 

wasting of, 38 
Mydriasis, irritative, 455 

paralytic, 455 
Myocardial degeneration, 282 
Myocarditis, acute, 282 
diagnosis, 284 
interstitial, 282 
parenchymatous, 282 
pathology, 282 
physical signs, 283 
suppurative, 283 
chronic, 284 
diagnosis, 285 
pathology, 284 
physical signs, 285 
fibrous, 284 
Myocardium, 188 

diseases of, 282 
Myoidema, 142 
Myomalacia cordis, 442 
My o sis, irritative, 455 

paralytic, 455 
Myotonia congenita, 402 



N 



Nails, analysis, 419 

arrested growth, 419 

atrophy, 419 

brittleness, 419 

capillary pulse, 417 

cyanosis, 417 

examination of, 417 

grooves, 417 

hypertrophy, 419 

incurvation, 418 

indolent sore, 419 

pallor, 417 

paronychia, 419 

ridges, 418 
Neck, elongation, 409 

examination of, 409 

shape, 40, 409 

short, 40, 409 
Neoplasms, pulmonary, 114 
Nerve, abducent, examination of, 453 

auditory, examination of, 459 

facial, examination of, 457 

glossopharyngeal, examination of, 
467 

hypoglossal, examination of, 402 
467 

oculomotor, examination of, 453 

olfactory, examination of, 448 

optic, examination of, 449 

pneumo-gastric, examination of, 
467 

spinal accessory, examination of, 
467 

trigeminal, examination of, 456 

trochlear, examination of, 453 



Nervous system, examination of, 438 
Neurone, motor, lower, 438 
sensory, 439 
upper, 438 
Nipple as landmark of thorax, 32 
Nodding spasm, 383 
Nodes, bronchial, 25 

Heberden's, 421 

inguinal, 314 

lymphatic pulmonary, 25 
Nodosities, Haygarth's, 421 
Noma, 400, 406 
Nose, examination of, 394 

pseudo-membrane, 395 

redness, 394 

saddle, 394 

shape, 394 

ulceration, 395 
Notch, dicrotic, 206 

suprasternal, 31, 35 
pulsation in, ^195 

umbilical, 353 
Note, tracheal, Williams', 79 

in serofibrinous pleurisy, 174 
Nun's murmur, 241 
Nystagmus, 455 

aural, 455 



O 



Obesity, contour of abdomen in, 318 
Occipital glands, enlargement, 413 
Oculocardiac reflex, 393 
Oligopnea, 51 

Oliver's estimation of venous pres- 
sure, 252 

sign, 241 
Onychogryposis, 419 
Onychia, 419 
Orifice, aortic, 187 

auriculo-ventricular, 187 

cardiac, 332 

pyloric, 332 
Orthopnea, 53, 256 
Osteal resonance, 70 
Osteitis deformans, facies in, 385 
Osteoarthropathy, pulmonary, 428, 

432, 437 
Osteomalacia, 436 
Othematoma, 384 
Otitis media, 384 
Otomycosis, 384 
Ovarian cyst, 323 



Paget 's disease, 436 
Palate perforation, 407 

paralysis, 407 
Palpation of abdomen, 324 
of bladder, 377 
of gall-bladder, 358 



IXDKX 



489 



Palpation — Cont M. 

ut' intestine, Large, 345 
small, 340 

of kidney, 370 

of liver, 357 

of precordia, 202 

of spleen, 363 

of stomach, 336 

of thorax, 55 

of ureter, 378 

technic of, 55 

ulnar, 5.1 
Palpatory percussion, 68 
Pancreas, clinical anatomy, 348 

cyst of, 348 

examination of, 348 

tumor of, 351 
Pancreatization of lung, 148 
Paradoxical pulse, 211 

in chronic adhesive pericarditis, 

260 
in chronic serofibrinous, peri- 
carditis, 257 
Paralysis, abducent, 456 

agitans, gait of, 442 
propulsion in, 442 
retropulsion in, 442 
tremor of, 425 

brachial, 428 

bulbar, chronic, 397 

Duchenne-Erb type, 428 

facial, 458 

flaccid, 442 

glossodabiodaryngeal, 402 

glosso-pharyngeal, 467 

hypoglossal, 468 

Klumpke tvpe, 428 

of leg, 437 

of palate, 407 

of tongue, 407 

pneumo-gastric, 4(57 

pseudodivpei trophic muscular, 432 

spastic, 442 

spinal accessory, 468 

trigeminal, 457 

trochlear, 456 
Paralytic thorax, 40 
Paramyoclonus multiplex, 429 
Parasternal line, 34 
Paravertebral dullness, 76 

Grocco's triangle of, 76, 174 
Parenchymatous myocarditis, 282 
Paresis, 442 
Parietal pleura, 17 
Paronychia, 419 

Parotid gland enlargement. 413 
Paroxysmal tachycardia, 227 
Parosmia, 449 
Patch, mucous, 406 

smoker 's, 404 
Patent ductus arteriosus. 294 

foramen ovale, 293 



Pause, compensatory, of heart, 226 
Pectoriloquy, 88 

whispering, 89 
Pellagra, forearms in, 426 

gum3 in, 401 

tongue in, 405 
Pelvis, 295 
Percussion, cardiac, 215 

deep, 68 

finger, 65 

force of, 68 

immediate, 65 

in intestinal obstruction. 341 

instrument, 65 

of abdomen, 321) 

of anterior chest wall, 70 

of axillary region, 7<» 

of back, 70 

of bladder, 377 

of heart, 214 

of intestine, small, 34] 

of kidney. 'Ml 

of liver, 359 

of lungs, 70 

of spleen, 366 

of stomach. 

of thorax, 65, 70 

palpatory, 68 

sense of resistance in, 65, 7c 

sound, 69 

attributes of, 69 
dull, 76 
duration, 69 
flat, 76 

hyper-resonant, 76 
intensity, 69 
pitch, 69 
quality, 69 
resonant, 70 
special, 78 
tympanitic, 78 
Pericardial friction, 24(1 
fremitus, 202 
succussion, 240 
Pericarditis, 253 

adhesive, chronic, 259 

Broadbent's sign in, 260 
diagnosis, 261 
Friedreich's sign in, 260 
Kussmaul's sign in, 260 
pathology, 259 
physical signs, 260 
external, 259 
fibrinous, acute, 253 
diagnosis, 255 
distinguished from Corrigan 's 

disease, 255 
pathology, 253 
physical signs, 254 
internal, 259 



490 



INDEX 



Pericarditis — Cont 'd. 
sero-fibrinous, 256 

Auenbrugger 's sign in, 256 
diagnosis, 258 

distinguished from cardiac dila- 
tation, 258 
distinguished from sero-fibrinous 

pleurisy, 258 
Ewart's sign in, 257 
milk spots in, 256 
pathology, 256 
physical signs, 256 
Rotch's sign in, 257 
sicca, 253 
with effusion, 256 
Pericardium, clinical anatomy, 189 

diseases of, 256 
Perihepatitic friction, 331 

peritoneal function, 331, 367 
Period, refractory of heart, 226 
Perisplenitic friction, 331 
Perisplenitis, peritoneal function in 

330, 367 
Peristalsis, visible, of intestine, 314 

of stomach, 314, 335 
Peritoneal friction, 331 
in peritonitis, 331 
Pes planus, 431 
Pharynx, bulging, 407 
eruptions, 407 
examination of, 407 
redness, 407 
ulceration, 407 
Phenomenon, Biermer's, 185 

Litten's, 48 
Phlegmasia, alba, dolens, 437 
Phlegmon, ligneous, 416 

woody, 416 
Phthisical thorax, 32, 40, 138 
Phthisis, broncho-pneumonic, acute, 
132 
chronic ulcerative, 133 (See Chron- 
ic ulcerative phthisis) 
fibroid, 144 (See Fibroid phthisis) 
mill-stone maker's, 153 
pneumonic, acute, 132 
stone-cutter's, 153 
tuberculo-pneumonic, acute, 132 
Physiologic venous pulse, 196 
Pigeon breast, 44 
cross-section of, 44 
in rickets, 45 
Pitch of percussion sound, 69 
Pleura, diseases of, 169 
parietal, 17 
surface markings, 27 
visceral, 17 
Pleural adhesions, 172, 180, 182 
cavity, clinical anatomy, 17 

dropsy, 184 (See also Hydro- 
thorax) 



Pleural cavity — Cont 'd. 
effusion into, 171 
friction, 90, 92, 170, 173 
sinus, complementary, 28 
Pleurisy, adhesive, chronic, 182 
diagnosis, 183 
pathology, 182 
physical signs, 182 
diaphragmatic, 177 
diagnosis, 178 
pathology, 177 
physical signs, 177 
fibrinous, acute, 169 

distinguished from intercostal 

neuralgia, 171 
distinguished from pleuro- 
dynia, 170 
pathology, 169 
physical signs, 170 
purulent, Baccelli's sign in, 18 L 
diagnosis, 182 
Grocco's sigh in, 181 
pathology, 179 
physical signs, 181 
sero-fibrinous, 171 

Baccelli's sign in, 175 
diagnosis, 175 

distinguished from hepatic tu- 
mor, 177 
from hydrothorax, 176 
from lobar pneumonia, 175 
from pneumothorax, 177 
from pulmonary neoplasm, 176 
Grocco's sign in, 174 
pathology, 171 
physical signs, 172 
uni-lateral bulging in, 172 
visceral displacement in, 172 
Pleuritis, sicca, 169 
Pleuro-pericarditis, 259 
Pleximeter, 65 
Plexor, 65 

Pneumonia, alba, of fetus, 148 
apical, 118 
catarrhal, 123 
central, 118 
croupous, 116 
deglutition, 124 
double, 118 

interstitial, chronic, 129 
lobar, 116 
lobular, 123 
massive, 118 
migratory, 118 
syphilitic, 148 
Pneumonic phthisis, acute, 132 
Pneumonokoniosis, 150 
diagnosis, 153 
pathology, 150 
phthisis and, 153 
physical signs, 153 





INDEX 491 


Pneumo-pericardium, 262 




Pulmonary — Cont 'd. 


diagnosis, 263 




neoplasms, 114 


pathology, 262 




diagnosis, 115 


physical signs, 262 




pathology, 114 


Pneumothorax, 184 




physical signs, 114 


Biermer's phenomenon in 


L85 


osteoarthropathy, 428, 432, 437 


closed, 185 




sound, accentuation of, 22:; 


coin test in, 185 




weakening of, 223 


diagnosis, 3 86 




stenosis, 280 


distinguished from hydrothorax 


diagnosis, 280 


176 




pathology, 280 


from serofibrinous pleurisy, 176 


physical signs, 280 


gutto cadens in, 185 




Pulsations, abnormal, areas of, 54, 


lung-fistula sound in, 186 




64, 194 


open, 185 




at base of heart, 54, 64, 194 


pathology, 184 




of left lung, 54 


physical signs, 185 




of left sternal border, 195 


succussion in, 186 




of right sternal border, 194, 279 


tympany in, 185 




carotid, 287 


Point, McBurney's, 346 




diastolic, 195 


Signorelli 's, 365 




epigastric, 195, 276 


Polypnea, 51 




in episternal notch, 195 


Portal vein, obstruction, 38 




in neck, 276 


caput medusae in, 38, •' 


510 


localized, of thorax, lA 


Post-dicrotic wave, 206 




of jugular veins, 196, 237, 276, 280 


Post-pharyngeal abscess, 407 




of left axilla, 54 


Potter's asthma, 153 




of liver, 195, 237, 276, 281, 290, 


Poupart's ligaments, 297 




355 


Power, muscular, I 12 




systolic, 195, 276 


Precordia, bulging of, 194, 2 


56 


Pulse, allorrhytlunic, 210 


retraction of, 194 




analysis of, 207 


Pregnancy, abdominal, contour in, 


arterial. 195 


318 




arterial changes in, 207 


Pressure, arterial, 242 




bilateral symmetry, 213 


blood, 242 




capillary, 201, 417 


diastolic, 244, 251 




centripetal venous, 198 


systolic, 244, 250 




Corrigan, 213 


venous, 251 




dicrotic, 212 


instrumental estimation 


251 


duration of, 212 


Oliver's method, 252 




force of, 211 


Presystolic murmur, mitral. 


232 


hyper-tension of, 212 


tricuspid, 236 




hypo-tension of, 212 


thrill, 281 




in aortic insufficiency, 272 


Ptosis of eyelid, 391 




in cardiac dilatation, 291 


of intestine, 323 




hypertrophy, 287 


of stomach, 323 




in chronic adhesive pericarditis, 260 


Pubic spine, 297 




myocarditis, 285 


symphysis, 297 




in mitral insufficiency, 277 


Puerile respiration, 87 




stenosis, 278 


in bronchiectasis, 105 




in pulmonary insufficiency, 279 


in compensatory emphysema, 162 


stenosis, 278 


in pneumothorax,185 




in sero-fibrinous pericarditis, 257 


Pulmonary area, 220 




in tricuspid insufficiency, 279 


artery, clinical anatomy. 


1SS 


stenosis, 280 


infarction, 279 




intermission of, 210 


insufficiency, 279 




paradoxical, 211 


diagnosis, 279 




pressure, 244, 251 


pathology, 279 




diminished, 250 


physical signs, 279 




increased, 250 


murmur. 237 




rate of, 207 


diastolic, 23S 




disturbances of, 20S 


systolic, 237 




rhythm of, 210 



492 



INDEX 



Pulse— Cont 'd. 

taking, technic of, 204 

tension of, 212 

venous, 196 

volume of, 211 

water-hammer, 213, 272 
Pulsus alternans, 211 

bigeminus, 211 

celer, 212 

deficiens, 210 

durus, 212 

intercidens, 211 

intermittens, 211 

magnus, 211 

mollis, 212 

paradoxus, 211, 257 

parvus, 211 

tardus, 212 

trigeminus, 211 
Pupil, Argyll-Robertson, 454 

reflexes of, 453 
Pupillary unrest, 454 
Purulent infiltration, 163 

pleurisy, 179 
Putrid bronchitis, 102 
Pyelonephrosis, fluctuation in, 373 
Pylorus, clinical anatomy, 332 
Pyo-pneumo-pericardium, 262 
Pyo-pneumo-thorax, 184 
Pyorrhea alveolaris, 401 

Q 

Quality of murmurs, 231 
of percussion sound, 69 



R 



Rachitic rosary, 38, 43 

thorax, 40 
Radial sphygmogram, 206 
Radiography, 95 
Rales, 90 

crepitant, 91 

dry, 90 

gurgling, 91 

in acute bronchitis, 101 

in bronchial asthma, 107 

in broncho-pneumonia, 126 

in chronic bronchitis, 103 
pleurisy, 183 

in emphysema, 159, 160, 162 

in lobar pneumonia. 120 

in phthisis, 133, 143, 148 

in pulmonary congestion, 111 
edema, 112 
infarction, 113 

in tracheal and bronchial stenosis, 
109 

indux, 91, 120 

moist, 90 

mucous, 91 

redux, 91, 120 



Rales — Cont 'd. 

sibilant, 90, 101, 103 
sonorous, 90 
subcrepitant, 91 
Ranula, 405 
Rate of pulse, 207 
Raynaud's disease, 422 
Rays, roentgen, 95 
Reaction, pupillary, Wernicke 's, 452 
Recession of thorax, expiratory, 47 
Recurrent endocarditis, 264 
Reflex accommodation, 454 
arc, 446 
light, 453 

consensual, 454 
oculo-cardiac, 393 
patellar, 446 
plantar, 447 
tendo-Achilles, 447 
Region, axillary, 35 
epigastric, 305 
hypochondriac, 35, 305 
hypogastric, 306 
infra-axillary, 35 
infra-clavicular, 35 
infra-scapular, 36 
inter-scapular, 36 
iliac, 307 
lumbar, 306 
mammary, 35 
scapular, 36 
sternal, 35 
supra-clavicular, 35 
supra-scapular, 36 
umbilical, 305 
Regurgitation, aortic, 270 
mitral, 276 
pulmonary, 279 
tricuspid, 280 
Reptilian heart, 293 
Resistance, increase of, 64 

sense of, 65, 70 
Resonance, amphoric, 78 
cracked-pot, 78 
impaired, 74 
money-chink, 78 
osteal, 70 
pulmonary, 70 

diminished at apices, 71 
diminution of anterior border, 

60, 71 
diminution of lower border, 74 

160 
extension of anterior border, 71 
extension of lower border, 74 
general decrease, 71, 159 

increase, 71 
increased at apices, 71 
limits of, 71 

variations in, 71 
regional variations, 70 
skodaic, 77 



INDEX 



4JJ3 



Resonance — Cont 'd. 

vesicular, 70 

vocal, 88 
Bespiration, 47 

absent, 87 

amphoric, 86 

bronchial, 85, 86 

broncho-vesicular, 85, 86 

cavernous, 65 

Cheyne-Stokes, 52 

cog-wheel, 87, 143 

costal, 47 

costo-abdominal, 47 

frequency of, 47, 52 

in acute fibrinous pleurisy, 170 
peritonitis, 51 

tuberculo-pneumonic phthisis, 
133 

in ascites, 51 

in bronchial asthma, 51, 107 

in bronchiectasis, 105 

in broncho-pneumonia, 51 

ui cerebral abscess, 51 
hemorrhage, 51 
tumor, 51 

in chronic adhesive pleurisy, 183 
bronchitis, 102 
interstitial pneumonia, 131 

in diabetes mellitus, 51 

in edema of glottis, 51 

in emphysema, 51, 159, 160, 162 

in laryngeal stenosis, 51, 141 

in laryngismus stridulus, 51 

in lobar pneumonia, 51, 119 

in meningitis, 51 

in phthisis, 51, 143 

in pleurisy with effusion, 172 

in pulmonary congestion, 51 
edema, 51 

in tonsillar hypertrophy, 51 

in tracheal stenosis, 51 

in uremia, 51 

movements of, 47 

normal, 83 

pathologic variations, 51, 86 

phases of, 47 

prolonged expiration, 40, 51, 87 

puerile, 87, 105, 162, 185 

rapid, 51 

slow, 50 

stertorous, 51 

stridulous, 51 

vesicular, 85, 86 
Respiratory organs, disease of, 100 

examination of, 37 
Retraction, local of thorax, 47 

uni-lateral of thorax, 46 
Rhagades, 397 
Rhonchal fremitus, 63 

in acute bronchitis, 63, 101 

in bronchial asthma, 63 

in chronic bronchitis, 102 



Rhonchal fremitus — Cont '<!. 

in phthisis, 63, 142 

in pulmonary edema, 1 1 2 
Rhonchi, 90 
Rhythm, canter, 224, 292 

gallop, 224, 284, 292 

of pulse, 210 
Ribs, as landmarks of thorax, 32 

incurvation of, 44 

method of counting 32 

obliquity of, 40 

overlapping of, 46 

prominence of, 38, 40 
Rickets, 44 

bowing of tibiae in, 432 

how-legs in, 437 

epiphyseal swelling in, 428 

funnel-chest in, 46 

I [arrison 's sulcus in, 44 

head of, 379 

keel In-cast in, 44 

knock-knees in, 437 

rosary in. 38, 43 

thorax of. 40 

Riedel 's lobe, 358 

Rigidity of abdominal wall, 326 

of rectus, 326 

Risus sardonicus, 390 

Riva-Rocci sphygmomanometer, 2 16 

Roentgenogram, 95 
in aneurism, aortic, 99 
in chronic Interstitial pneumonia, 

98 
in lobar pneumonia, 98 
in mediastinal neoplasm, 98 
in pleural thickening, 98 
in pleurisy with effusion, 98 
in pneumo-thorax, 98 
in pulmonary neoplasm, 9S 
in sero-fibrinous pericarditis, 98 
in tuberculosis, pulmonary, 96 
of heart, 99 

Roentgenography. 95 

Roentgen rays, 95 

Rogers' sphygmomanometer, 246 

Rosary, rachitic, 38, 43 

Rotch's sign, 257 



Saddle nose, 394 
Safety-valve murmur, 182 
Sarcoma of lung, 114 
Scaphoid abdomen, 323 
Scapula, angle of, 32 

as landmark of thorax, 32 

winged, 40 
Scapular line, 34 
spinal, 35 

region, 36 
Scarpa's triangle, swelling in, 436 



494 



INDEX 



Scars of abdomen, 308 

of neck, 416 

of thorax, 38 
Sclera, blue, 384 

yellow, 394 
Scleritis, 394 
Sclerosis of lung, 129 
Scoliosis, 44, 146 
Scotoma, 451 

absolute, 452 

relative, 452 
Scrobiculus cordis, 31, 35 
Scybala, 340 
Seal-fin hand, 425 

Semilunar space of Traube, 332, 338 
Sensation, muscular, 445 

pain, 445 

pressure, 445 

stereognostic, 446 

tactile, 444 

temperature, 444 

Septa, cardiac, 187 

absence of, 293 

interventricular, defects of, 293 
Sero-fibrinous pericarditis, 256 

pleurisy, 171 
Shock, valve, 202, 278, 287 
Sibilant rales, 91, 101, 103 
Siderosis, 150 
Sigmoid flexure, clinical anatomy, 343 

palpation of, 348 
Sign, Abadie's, 390 

Auenbrugger 's, 256 

Babinski's, 447 

Baccelli's, 89, 175, 181 

Biermer's, 80 

Broadbent's, 198, 260 

Duroziez's, 272 

E wart's, 257 

Friedreich's, 80, 142, 165, 196 

Gerhardt's, 80, 105, 142, 165 

Glenard's, 338 

Grocco's, 76, 174, 181 

Kernig's, 443 

Kussmaul's, 260 

Litten's, 48 

Lorenz's, 138 

Oliver's, 241 

Prevost's, 456 

Romberg's, 440 

Rotch's, 257 

Rothschild's, 138 

Yon Graeffe's, 393 

Williams', 95 

Wintrich's, 79, 105, 142 
Signorelli's point, 365 
Simple endocarditis, 264 
Sinus, complementary, 28 

of Valsalva, 187 
Sixth costal line, 35 
Skiagraphy, 95 



Skin, of abdomen, 308 
colors of, 308, 309 
eruptions of, 308 
scars of, 308 
of thorax, 38, 39 
eruptions of, 38 
pigmentation of, 38 
Skodaic resonance, 77 
in lobar pneumonia, 119 
in sero-fibrinous pericarditis, 78 
pleurisy, 174 
Snoring respiration, 51 
Sonorous rales, 90, 101, 103 
Souffle, umbilical, 331 

uterine, 331 
Sound, aortic, accentuation of, 222, 
285, 287 
diminution of, 223 
cracked-pot, 78, 105, 142, 174 
falling-drop, 90, 91, 185 
friction, pericardial, 239 
perihepatitic, 331 
perisplenitic, 331 
peritoneal, 331 
pleural, 90, 92, 170, 175 
lung-fistula, 90, 93, 185 
mitral, accentuation of, 222, 287 

diminution of, 222, 279 
percussion, 69 
abnormal, 74 

change of, Friedreich's, 80, 142, 
165, 196 
Gerhardt's, 80,. 105, 142, 165 
Wintrich's, 79, 105, 142, 165 
cracked-pot, 78-105, 142, 174 
dull, 76 
duration of, 69 
flat, 76 

hyper-resonant, 76 
intensity of, 69 

interrupted change of Win- 
trich's, 79 
normal, 70 
pulmonary, accentuation of, 223, 
258, 279 
diminution of, 223, 281 
pitch of, 69 
quality of, 69 
special, 78 
tympanitic, 78 
splashing, 90, 92 
succussion, pericardial, 240 
Sounds, adventitious, 89, 224 
cardiac, 219 

accentuation of, 221 
diminution of, 221 
reduplication of, 222 
extraneous, 83 
respiratory, 83 
Spaces, intercostal, 32 
bulging of, 125 



INDEX 



495 



Spaces — Cont 'd. 

aarrowing of, 46, 140, 160 

retraction of, 40, 51, 155 

Traube \s semilunar, 332, 338 
Spade-hand, 422 
Spasm, brachial, 430 

choreal, 390 

facial, 391 

habit, 390 

lingual, 402 

nodding, 383 

of exophthalmic goiter, 390 

professional, 426 

tetanic, 390 
Sphygmogram, arterial, 206 
clinical significance, 206 
variations in, 206 
Sphygmomanometer, Cook's, 243 

Erlanger's, 244 

Faught's, 246 

Janeway's, 245 

Riva-Rocci's, 246 

Rogers', 246 

Stanton's, 243 
Sphygmomanometry, auscultatory 
method, 249 

palpatory method, 248 

1 <'clmic, 246 
Spine, iliac, 297 

anterior superior, 297 
Spiral's, Curschmann 's, 107 
Splashing sounds, 92 
Spleen, auscultation of, .".<i7 

clinical anatomy of, 363 

displacement of, 366 

enlargement of, 364 

examination of, 363 

inspection of, 363 

palpation of, 363 

percussion of, 366 

point, Signorelli 's, 365 

surface marking, 363 

tenderness of, 365 

wandering, 366 
Spots, cold, 444 

heat, 444 

milk, 256 
Sputum, in bronchial asthma, 106 

in bronchiectasis, 105 

in broncho-pneumonia, 125 

in chronic ulcerative phthisis, 141 

in lobar pneumonia, 117 

in pulmonary abscess, 165 
edema, 112 
gangrene, 167 
Squint, 455 

Stanton's sphygmomanometer, 243 
Staphyloma, 394 
Station, 440 

Stenosis, aortic, 273 (See Aortic 
stenosis) 



Stenosis — Cont'd. 

mitral, 277 (See Mitral stenosis; 

of bronchi, 108 

of trachea, 108 

pulmonary, 280 (See Pulmonary 

stenosis; 
tricuspid, 281 (See Tricuspid sten- 
osis) 
Stereo-roentgenogram , 95 

Stereo -roentgenography, 95 
Sternal dullness, 70 

line, 33 

region, 35 
Sterno-mastoids, prominence of, 409 
Sternum, as landmark of thorax, 31 

length of, 31 

prominence of, 44 
Stethophone, 82 
Stethoscope, 82 

binaural, 82 

monaural, 82 

selection of, 82 
Stokes-Adams disease 228 
Stomach, auscultation of, 339 

auscultatory percussion of, •"••"• s 

clinical anatomy of, :;.",2 

fundus of, 332 

greater curvature of, '■'<■'•- 

hour-glass, 339 

inflation of, 338 

inspection of, 333 

lesser curvature of, 332 

orifice, cardiac. 332 
pyloric, 332 

palpation of, 336 

percussion of, 338 

peristalsis of, 335 

pit of, 31 

relations of, 332 

succussion sounds of, 337 

surfaces of. .",.".2 

tumor of, 336 

tympany of, ."..'Is 

decreased, 339 

increased, 339 
Stomatitis, catarrhal, 406 
gangrenous, 406 
ulcerative. 401 
Stone-cutter 's phthisis, 153 
Strabismus, 445 
Stridulous respiration, 51 
Subclavian artery, auscultation of, 
241 
murmur in, 241 
Subcostal line, 304 
Subcrepitant rale, 91 
Subcutaneous nodules of forehead, 

391 
Submaxillarv lymph nodes, enlarged. 
413 



496 



INDEX 



Succussion, fremitus, 63, 186 
in pneumo-thorax, 63, 186 
pulmonary cavity, 63 
Hippocratic, 337 
pericardial, 240 
sound, 337 
Sulcus, Harrison's, 44 
Supra-clavicular fossa, 39 
region, 35 

recession of, 40 
Supra-scapular fossa, 36 

region, 36 
Supra-sternal notch, 31, 35 
Surgical kidney, 373 
Sutures, open, 380 
Symphysis pubis, 297 
Syphilis, pulmonary, 148 
acquired, 148 
hereditary, 148 
pathology, 148 
physical signs, 149 
Syphilitic broncho-pneumonia, 148 

fibrosis of lung, 148 
Systole, auricular, 196 

ventricular, 244 
Systolic jugular pulsation, 196, 280 
murmurs, 231 
aortic, 234 
arterial, 240 
mitral, 233 
pulmonary, 237 
tricuspid, 236 
plateau, 207 
pressure, 244 
pulsation, epigastric, 195 
retraction of thorax, 198 
venous pulse, 197 



Tachycardia, 210, 227 

paroxysmal, 227 
Talipes, equinus, 432 

valgus, 432 

varus, 432 
Teeth, delayed, 400 

early decay, 400 

examination of, 400 

grinding, 401 

Hutchinson's, 401 

loosening, 400 

premature, 400 
Tenderness of abdomen, 326 
points of, 327 

of thorax, 63 
Tension of pulse, 212 
Test, Barany's, 460 

caloric, 462 

Gairdner's, 81, 185 

Holmgren, 450 

pointing, 464 

rotation, 463 



Thermo-anesthesia, 445 
Thermo-hyperesthesia, 445 
Thigh, edema of, 436 

tumor of, 436 
Third costal line, 35 
Thomson's, 451 
Thoracometry, 94 

Thorax, abnormalities of expansion, 
53 

alar, 40 

bi-lateral deformities of, 40 • 

clavicles as landmark of, 31 

clinical anatomy of, 17 

contour of, 39 

diameter of, 39, 40, 43, 94, 158, 160 

edema of, 38, 54 

elongation of, 40 

emphysematous, 40, 158 

enlarged veins of, 38 

eruptions of, 38 

examination of, 37 

expansion of, 53,-55, 94 

flat, 40 

fluctuation of, 64 

funnel, 46 

inlet, 31 • 

inspection of, 37 

intercostal spaces as landmarks, 32 

landmarks of, 29 

local deformities of, 47 
enlargement of, 47 
retraction of, 47 

localized pulsations, 54, 64, 194 

mammary glands as landmarks, 32 

mensuration of, 94 

movements of, 94 

musculature of, 38, 39 
wasting of, 38, 40 

nipples as landmarks, 32 

normal, 39 

cross-section of, 39 
landmarks of, 29 

of child, 39 

cross-section of, 39 

palpation of, 55 

paralytic, 40 

percussion of, 65 

phthisical, 32, 40 

pigeon, 44 

cross-section of, 44 

pigmentation of, 38 

rachitic, 40 

cross-section of, 43 

regions of, 33 

ribs as landmarks of, 32 

scapulae as landmarks of, 32 

scars of, 38 

shortening of, 40 

size of, 39 

skin of, 38, 39 

spine as landmark of, 32 



INDEX 



497 



Thorax — Cont VI. 

sternum as landmark, 38 
subcutaneous tissues of, 38 

surface of, 38 

systolic retraction of, 198 

tenderness of, 63 

uni-lateral contraction of, 46 
deformities of, 46 
enlargement of, 46 

vibrations of, 58 
Thrill, 203 

at apex, 204, 275 

aortic area, 204, 275 
base of heart, 204 
pulmonary area, 204 

cardiac, 203 

diastolic, 203 

hemic, 203 

in mitral stenosis, 278 

over carotids, 20 \ 

presystolic, 203, 276 

systolic, 203, 276 
Thrush, 405 
Thyroid gland, atrophy of, 412 

enlargement, 411 

fluctuation of, 411 

murmur over, 411 

thrill over, 411 
Tic, convulsive, .".DO 
Tinkle, metallic, 89, 91 
Tinnitus, 460 
Toes, examination of, 431 

gangrene of, 4.",1 

in gout, 431 

perforating ulcer of. 431 
Tone, tracheal, Williams', 79 
Tongue, atrophy, 401 

color, 405 

cysts, 405 

examination of, 401 

geographical, 404 

hypertrophy, 401 
acquired, 401 
congenital, 401 

indentations, 405 

in pellagra, 405 

leukoplakia, 404 

movements, 402 

paralysis, 402 

size of, 401 

smoker's patch, 404 

spasm, 402 

strawberry, 406 

thrush, 405 

tremor, 402 

ulceration, 402 
Tonsillitis, follicular, 407 
Tonsils, enlargement of, 408 

examination of, 407 

inflammation of, 407 



Tonsils — Cont 'd. 
pseudo-membrane on. 408 
ulceration of. 4os 
Tophi, 384, 419 
Torticollis, congenital, 409 
rheumatic, ::^i! 
spasmodic, 409 
Tortuosity of abdominal veins, 310 
Toxemic dyspnea, 53 
Tracheal tone, Williams, 79 

tug, 241, (11 
Trachea, clinical anatomy, 10 
deflection of, 409 
surface markings^ 29 
Tracheo-bronchia] stenosis, 108 
diagnosis, 1"0 
pathology, Ins 
physical si^ns. 108 
Traube's semilunar space. 332, :::;s 
decrease of, 339 
dullness of. 257, 260 
increase of, 131, 339 
Tremor, convulsive. 44.". 
intention, 125, 44.". 
of tongue, 4 ( f i_> 
pill-rolling, 420. 44". 
Tricuspid insufficiency 
diagnosis, 281 
pathology of, - 

physical si;_;ii>. 280 
pulse in. 281 
relative, 280 
murmur, 236 
presystolic, 236 
systolic. 236 
stenosis, 281 

pathology of. 281 
physical signs, 283 
valve, is; 

anatomic site of. 220 
auscultatory area of. 220 
Tuberculo-pneumonic phthisis, acute 

132 
Tuberculosis, pulmonary, 132 (See 

Phthisis) 
Tug, tracheal, 241. 400 
Tumor, intra-abdominal. 328 
of stomach. 336 
pulmonary. 114 
Tussile. fremitus, 63 
Twelfth dorsal line. 35 
Tympanites, respiration in. 4S 
Tympany bell, SI 
gastric, 338 

decrease of, 339 
increase of, 339 
in ascites. 323 

in bronchiectatic cavities. 78, 104 
in pneumo-thorax, 78 
in pulmonary cavities. 7S 
on percussion, 78 



498 



INDEX 



r, 



u 



Ulcer, carcinomatous, 395, 404, 408 

corneal, 394 

of leg, 432 

nasal, 395 

perforating, of foot, 431 

simple, 402 • 

syphilitic, 395, 403, 407 

tuberculous, 395, 403, 407 
Ulceration, peritonsillar, 408 
Umbilical hernia, 313 

notch, 353 

region, 305 
Umbilicus, eruptions of, 313 

inflammation, 313 

protrusion of, 313 

retraction of, 313 
Uni-lateral bulging of thorax, 46 

contraction of thorax, 46 
Unrest, pupillary, 454 
Ureters, examination of, 378 

palpation of, 378 

surface marking, 378 

tenderness of, 378 
Uvula, elongation of, 407 



Vagus neuritis, tachycardia in, 210 
Valsalva, sinus of, 187 
Valve aortic, 187 

anatomic site, 220 
auscultatory area, 220 
areas, 219 
ileo-cecal, 339 
mitral, 187 

anatomic site, 220 
auscultatory area, 220 
pulmonary, 188 

anatomic site, 220 
auscultatory area, 220 
shock, 202, 278, 287 
tricuspid, 187 

anatomic site, 220 
auscultatory area, 220 
Valves, cardiac, 187 
diseases of, 264 
excrescences of, 265 
of heart, 187 
perforation of, 270 
Valvular disease, chronic, 268 
effects of, 269 
incidence of, 269 
Varicose veins, 432 
Vascular dullness, 218 

murmurs, 240 
Vegetation, adenoid, 395 
Vein, common iliac, surface marking, 
302 
external iliac, surface marking, 302 
portal, obstruction, 38, 310 
'L caput medusae in, 38, 310 

BD- 79. 



Veins, cervical engorgement of, 256 
distended, of thorax, 38, 310 
fluid, 203, 229, 240 
jugular, diastolic collapse, 196 

pulsation of, 237 
pulmonary, 189 
varicose, 432 
Vena cava, inferior, surface markings, 
301 
superior, 189 
Venous hum, 241 
murmurs, 241 
pressure, 251 
pulse, auricular, 196 
centripetal, 198 
negative, 196 
physiologic, 196 
positive, 197 
presystolic, 196 
systolic, 197 
Ventricles, clinical anatomy, 187 
Ventricular, diastole, 244 

systole, 244 
Vermiform, appendix, 343 

palpation of, 346 
Vertebra prominens, 32 
Vertebrae, method of counting, 32 
Vertigo, 460 

Vesicular emphysema, acute, 162 
resonance, 70 
respiration, 86 
Vincent's angina, 408 
Viscera, abdominal, clinical anatomy, 
295 
examination of, 332 
thoracic, clinical anatomy, 19, 187 
Visceral pleura, 17, 20 
Visceroptosis, abdominal contour in, 

323 
Vision, color, 450 

field of, 451 
Vocal fremitus, 58 
absence of, 62 
decrease of, 62 
in atelectasis, 155 
in chronic ulcerative phthisis, 62, 

142 
in emphysema, hypertrophic, 62, 

158 
in lobar pneumonia, 62, 119 
in pneumo-thorax, 62, 185 
in pulmonary cavity, 62 
in sero-fibrinous pleurisy, 62, 173 
in tuberculo-pneumonic phthisis, 

acute, 132 
increase of, 62 
normal variations, 58 
resonance, 88 
absent, 88 
diminished, 88 
in acute bronchitis, 101 



INDEX 



499 



Vocal resonanci — Cont 'd. 

in ac^te fibrinous pleurisy, 170 
in bronchial asthma, 107 
in bronchiectasis, 105 
in chronic bronchitis, 103 
ulcerative phthisis, 143 
in emphysema, 159 
in pulmonary congestion, 111 

edema, 112 
in sero-fibrinous pleurisy, 175 
increased, 88 
modified, 89 

Volume of pulse, 211 

Von Graeffe's sign, 393 

W 

Wall, abdominal, 295 

edema, 326 

palpation, 324 

rigidity of, 326 

suppuration, 326 

thickness, estimation of, 324 
arterial, 207 
Wandering kidney, 373 

spleen, 366 
Water-hammer pulse, 213, -272 



Wave, dicrotic, 206 
fat, 327 

fluid, 326 
post-dicrotic, 206 
Wernicke's reaction. 452 
Whispering pectoriloquy. 
White spots, of nails. 417 
Williams* sign in phthisis, 95 

trachea] tone, 79, 174 
Wintrich's change of sound. 7!*. 105, 
142. 165 

in bronchiectasis, 105 
chronic ulcerative phthisis, 
42 
interrupted change of sound. 7'. 1 
Woillez's disease, 123 
Woody phlegmon, 416 
Wrist drop, 125 
Wry-neck, 82 



Xanthelasma, 405 

Xanthoma, 391 

Xerostomia, 406 

X-ray, 95 Set Roentgen r»ys) 






%> ^ *^W/v ^ ** *" 






O v 



% **rT 9 *p> V .^.» ^ 



♦♦*% 




lV 















£W 







^ ^ 
"^^ 













^S 












V .*^ 



^. 



..OS. .;#*£. V 

BINDING 

AUGUSTINE 



if 







